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Puvrez A, Duchenne J, Donal E, Gorcsan J, Patel HC, Marwick TH, Smiseth OA, Søgaard P, Stankovic I, Diogo PG, Vörös G, Voigt JU. Mechanical dyssynchrony as a selection criterion for cardiac resynchronization therapy: Design of the AMEND-CRT trial. ESC Heart Fail 2024. [PMID: 38984947 DOI: 10.1002/ehf2.14932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Revised: 05/25/2024] [Accepted: 06/14/2024] [Indexed: 07/11/2024] Open
Abstract
AIMS One third of patients do not improve after cardiac resynchronization therapy (CRT). Septal flash (SF) and apical rocking (ApRock) are deformation patterns observed on echocardiography in most patients eligible for CRT. These markers of mechanical dyssynchrony have been associated to improved outcome after CRT in observational studies and may be useful to better select patients. The aim of this trial is to investigate whether the current guideline criteria for selecting patients for CRT should be modified and include SF and ApRock to improve therapy success rate, reduce excessive costs and prevent exposure to device-related complications in patients who would not benefit from CRT. METHODS The AMEND-CRT trial is a multicentre, randomized, parallel-group, double-blind, sham-controlled trial with a non-inferiority design. The trial will include 578 patients scheduled for CRT according to the 2021 ESC guidelines who satisfy all inclusion criteria. The randomization is performed 1:1 to an active control arm ('guideline arm') or an experimental arm ('echo arm'). All participants receive a device, but in the echo arm, CRT is activated only when SF or ApRock or both are present. The outcome of both arms will be compared after 1 year. The primary outcome measures are the average change in left ventricular end-systolic volume and patient outcome assessed using a modified Packer Clinical Composite Score. CONCLUSIONS The findings of this trial will redefine the role of echocardiography in CRT and potentially determine which patients with heart failure and a prolonged QRS duration should receive CRT, especially in patients who currently have a class IIa or class IIb recommendation.
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Affiliation(s)
- Alexis Puvrez
- Department of Cardiovascular Diseases, University Hospitals Leuven, Leuven, Belgium
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | - Jürgen Duchenne
- Department of Cardiovascular Diseases, University Hospitals Leuven, Leuven, Belgium
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | - Erwan Donal
- LTSI, Inserm 1099, LTSI, University of Rennes, Rennes, France
- Department of Cardiology, CHU Rennes, Rennes, France
| | - John Gorcsan
- Heart and Vascular Institute, Penn State University College of Medicine, Hershey, Pennsylvania, USA
| | - Hitesh C Patel
- Department of Cardiology, Alfred Hospital, Melbourne, Victoria, Australia
- Central Clinical School, Monash University, Melbourne, Victoria, Australia
- Baker Heart and Diabetes Institute, Melbourne, Australia
| | | | - Otto A Smiseth
- Institute for Surgical Research, Oslo University Hospital and University of Oslo, Oslo, Norway
| | - Peter Søgaard
- Department of Cardiology, Aalborg University Hospital and University of Aalborg, Aalborg, Denmark
- Department of Cardiology, Rigshospitalet, Copenhagen, Denmark
| | - Ivan Stankovic
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
- Department of Cardiology, Clinical Hospital Centre Zemun, Belgrade, Serbia
| | - Pedro G Diogo
- Department of Cardiovascular Diseases, University Hospitals Leuven, Leuven, Belgium
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | - Gábor Vörös
- Department of Cardiovascular Diseases, University Hospitals Leuven, Leuven, Belgium
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | - Jens-Uwe Voigt
- Department of Cardiovascular Diseases, University Hospitals Leuven, Leuven, Belgium
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
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Lazăr-Höcher AI, Cozma D, Cirin L, Cozgarea A, Faur-Grigori AA, Catană R, Tudose DG, Târtea G, Crișan S, Gaiță D, Luca CT, Văcărescu C. A Comparative Analysis of Apical Rocking and Septal Flash: Two Views of the Same Systole? J Clin Med 2024; 13:3109. [PMID: 38892820 PMCID: PMC11172686 DOI: 10.3390/jcm13113109] [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: 03/28/2024] [Revised: 05/11/2024] [Accepted: 05/22/2024] [Indexed: 06/21/2024] Open
Abstract
Heart failure (HF) is a complex medical condition characterized by both electrical and mechanical dyssynchrony. Both dyssynchrony mechanisms are intricately linked together, but the current guidelines for cardiac resynchronization therapy (CRT) rely only on the electrical dyssynchrony criteria, such as the QRS complex duration. This possible inconsistency may result in undertreating eligible individuals who could benefit from CRT due to their mechanical dyssynchrony, even if they fail to fulfill the electrical criteria. The main objective of this literature review is to provide a comprehensive analysis of the practical value of echocardiography for the assessment of left ventricular (LV) dyssynchrony using parameters such as septal flash and apical rocking, which have proven their relevance in patient selection for CRT. The secondary objectives aim to offer an overview of the relationship between septal flash and apical rocking, to emphasize the primary drawbacks and benefits of using echocardiography for evaluation of septal flash and apical rocking, and to offer insights into potential clinical applications and future research directions in this area. Conclusion: there is an opportunity to render resynchronization therapy more effective for every individual; septal flash and apical rocking could be a very useful and straightforward echocardiography resource.
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Affiliation(s)
- Alexandra-Iulia Lazăr-Höcher
- Doctoral School, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania; (A.-I.L.-H.); (L.C.); (A.C.)
- Institute of Cardiovascular Diseases Timisoara, 13A Gheorghe Adam Street, 300310 Timisoara, Romania; (A.-A.F.-G.); (S.C.); (D.G.); (C.-T.L.); (C.V.)
| | - Dragoș Cozma
- Institute of Cardiovascular Diseases Timisoara, 13A Gheorghe Adam Street, 300310 Timisoara, Romania; (A.-A.F.-G.); (S.C.); (D.G.); (C.-T.L.); (C.V.)
- Department of Cardiology, “Victor Babes” University of Medicine and Pharmacy, 2 Eftimie Murgu Square, 300041 Timisoara, Romania;
- Research Center of the Institute of Cardiovascular Diseases Timisoara, 13A Gheorghe Adam Street, 300310 Timisoara, Romania
| | - Liviu Cirin
- Doctoral School, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania; (A.-I.L.-H.); (L.C.); (A.C.)
| | - Andreea Cozgarea
- Doctoral School, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania; (A.-I.L.-H.); (L.C.); (A.C.)
- County Clinical Emergency Hospital of Sibiu, 550245 Sibiu, Romania
| | - Adelina-Andreea Faur-Grigori
- Institute of Cardiovascular Diseases Timisoara, 13A Gheorghe Adam Street, 300310 Timisoara, Romania; (A.-A.F.-G.); (S.C.); (D.G.); (C.-T.L.); (C.V.)
| | - Rafael Catană
- Department of Cardiology, “Victor Babes” University of Medicine and Pharmacy, 2 Eftimie Murgu Square, 300041 Timisoara, Romania;
| | - Dănuț George Tudose
- Institute of Cardiovascular Diseases C.C. Iliescu, Fundeni Clinical Institute, 258 Fundeni Street, 022328 Bucharest, Romania;
| | - Georgică Târtea
- Department of Physiology, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania;
| | - Simina Crișan
- Institute of Cardiovascular Diseases Timisoara, 13A Gheorghe Adam Street, 300310 Timisoara, Romania; (A.-A.F.-G.); (S.C.); (D.G.); (C.-T.L.); (C.V.)
- Department of Cardiology, “Victor Babes” University of Medicine and Pharmacy, 2 Eftimie Murgu Square, 300041 Timisoara, Romania;
- Research Center of the Institute of Cardiovascular Diseases Timisoara, 13A Gheorghe Adam Street, 300310 Timisoara, Romania
| | - Dan Gaiță
- Institute of Cardiovascular Diseases Timisoara, 13A Gheorghe Adam Street, 300310 Timisoara, Romania; (A.-A.F.-G.); (S.C.); (D.G.); (C.-T.L.); (C.V.)
- Department of Cardiology, “Victor Babes” University of Medicine and Pharmacy, 2 Eftimie Murgu Square, 300041 Timisoara, Romania;
- Research Center of the Institute of Cardiovascular Diseases Timisoara, 13A Gheorghe Adam Street, 300310 Timisoara, Romania
| | - Constantin-Tudor Luca
- Institute of Cardiovascular Diseases Timisoara, 13A Gheorghe Adam Street, 300310 Timisoara, Romania; (A.-A.F.-G.); (S.C.); (D.G.); (C.-T.L.); (C.V.)
- Department of Cardiology, “Victor Babes” University of Medicine and Pharmacy, 2 Eftimie Murgu Square, 300041 Timisoara, Romania;
- Research Center of the Institute of Cardiovascular Diseases Timisoara, 13A Gheorghe Adam Street, 300310 Timisoara, Romania
| | - Cristina Văcărescu
- Institute of Cardiovascular Diseases Timisoara, 13A Gheorghe Adam Street, 300310 Timisoara, Romania; (A.-A.F.-G.); (S.C.); (D.G.); (C.-T.L.); (C.V.)
- Department of Cardiology, “Victor Babes” University of Medicine and Pharmacy, 2 Eftimie Murgu Square, 300041 Timisoara, Romania;
- Research Center of the Institute of Cardiovascular Diseases Timisoara, 13A Gheorghe Adam Street, 300310 Timisoara, Romania
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Sperlongano S, Benfari G, Ilardi F, Lisi M, Malagoli A, Mandoli GE, Pastore MC, Mele D, Cameli M, D'Andrea A. Role of speckle tracking echocardiography beyond current guidelines in cardiac resynchronization therapy. Int J Cardiol 2024; 402:131885. [PMID: 38382847 DOI: 10.1016/j.ijcard.2024.131885] [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: 07/22/2023] [Revised: 01/11/2024] [Accepted: 02/18/2024] [Indexed: 02/23/2024]
Abstract
Cardiac resynchronization therapy (CRT) is a device-based treatment applied to patients with a specific profile of heart failure. According to current guidelines, indication for CRT is given on the basis of QRS morphology and duration, and traditional transthoracic echocardiography is mainly used to estimate left ventricular (LV) ejection fraction. However, the identification of patients who may benefit from CRT remains challenging, since the application of the above-mentioned guidelines is still associated with a high rate of non-responders. The assessment of various aspects of LV mechanics (including contractile synchrony, coordination and propagation, and myocardial work) performed by conventional and novel ultrasound technologies, first of all speckle tracking echocardiography (STE), may provide additional, useful information for CRT patients' selection, in particular among non-LBBB patients, who generally respond less to CRT. A multiparametric approach, based on the combination of ECG criteria and echocardiographic indices of LV dyssynchrony/discoordination would be desirable to improve the prediction of CRT response.
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Affiliation(s)
- Simona Sperlongano
- Division of Cardiology, Department of Translational Medical Sciences, University of Campania Luigi Vanvitelli, Naples, Italy.
| | - Giovanni Benfari
- Section of Cardiology, Department of Medicine, University of Verona, Verona, Italy
| | - Federica Ilardi
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy; Mediterranea Cardiocentro, Naples, Italy
| | - Matteo Lisi
- Department of Cardiovascular Disease - AUSL Romagna, Division of Cardiology, Ospedale S. Maria delle Croci, Ravenna, Italy
| | - Alessandro Malagoli
- Division of Cardiology, Nephro-Cardiovascular Department, Baggiovara Hospital, University of Modena and Reggio Emilia, Modena, Italy
| | - Giulia Elena Mandoli
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
| | - Maria Concetta Pastore
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
| | - Donato Mele
- Department of Cardiac Thoracic Vascular Sciences, University of Padua, Padua, Italy
| | - Matteo Cameli
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
| | - Antonello D'Andrea
- Division of Cardiology, Department of Translational Medical Sciences, University of Campania Luigi Vanvitelli, Naples, Italy; Department of Cardiology, Umberto I Hospital, Nocera Inferiore, Italy
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Catrina BI, Batar F, Manitiu I, Prodan L, Tanasescu C, Filip T. Concepts of Cardiac Dyssynchrony and Dynamic Approach. Diagnostics (Basel) 2024; 14:937. [PMID: 38732350 PMCID: PMC11083078 DOI: 10.3390/diagnostics14090937] [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: 02/21/2024] [Revised: 04/12/2024] [Accepted: 04/24/2024] [Indexed: 05/13/2024] Open
Abstract
Cardiac conduction involves electrical activity from one myocyte to another, creating coordinated contractions in each. Disruptions in the conducting system, such as left bundle branch block (LBBB), can result in premature activation of specific regions of the heart, leading to heart failure and increased morbidity and mortality. Structural alterations in T-tubules and the sarcoplasmic reticulum can lead to dyssynchrony, a condition that can be treated by cardiac resynchronization therapy (CRT), which stands as a cornerstone in this pathology. The heterogeneity in patient responses underscored the necessity of improving the diagnostic approach. Vectocardiography, ultra-high-frequency ECG, 3D echocardiography, and electrocardiographic imaging seem to offer advanced precision in identifying optimal candidates for CRT in addition to the classic diagnostic methods. The advent of His bundle pacing and left bundle branch pacing further refined the approach in the treatment of dyssynchrony, offering more physiological pacing modalities that promise enhanced outcomes by maintaining or restoring the natural sequence of ventricular activation. HOT-CRT emerges as a pivotal innovation combining the benefits of CRT with the precision of His bundle or left bundle branch area pacing to optimize cardiac function in a subset of patients where traditional CRT might fall short.
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Affiliation(s)
- Bianca Iulia Catrina
- County Clinical Emergency Hospital of Sibiu, 550245 Sibiu, Romania; (F.B.); (I.M.); (C.T.); (T.F.)
- Pathophysiology Department, Faculty of Medicine, Lucian Blaga University of Sibiu, 550169 Sibiu, Romania
| | - Florina Batar
- County Clinical Emergency Hospital of Sibiu, 550245 Sibiu, Romania; (F.B.); (I.M.); (C.T.); (T.F.)
- Physiology Pathophysiology Department, Faculty of Medicine, Lucian Blaga University of Sibiu, 550169 Sibiu, Romania
| | - Ioan Manitiu
- County Clinical Emergency Hospital of Sibiu, 550245 Sibiu, Romania; (F.B.); (I.M.); (C.T.); (T.F.)
- Cardiology Department, Faculty of Medicine, Lucian Blaga University of Sibiu, 550169 Sibiu, Romania
| | - Liliana Prodan
- County Clinical Emergency Hospital of Sibiu, 550245 Sibiu, Romania; (F.B.); (I.M.); (C.T.); (T.F.)
- Pathophysiology Department, Faculty of Medicine, Lucian Blaga University of Sibiu, 550169 Sibiu, Romania
| | - Ciprian Tanasescu
- County Clinical Emergency Hospital of Sibiu, 550245 Sibiu, Romania; (F.B.); (I.M.); (C.T.); (T.F.)
- Clinical Surgical Department, Faculty of Medicine, Lucian Blaga University of Sibiu, 550169 Sibiu, Romania
| | - Teodora Filip
- County Clinical Emergency Hospital of Sibiu, 550245 Sibiu, Romania; (F.B.); (I.M.); (C.T.); (T.F.)
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Amaral Marques C, Laura Costa A, Martins E. Left bundle branch block-induced dilated cardiomyopathy: Definitions, pathophysiology, and therapy. Rev Port Cardiol 2024:S0870-2551(24)00081-7. [PMID: 38615881 DOI: 10.1016/j.repc.2024.02.004] [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: 05/03/2023] [Revised: 11/18/2023] [Accepted: 02/07/2024] [Indexed: 04/16/2024] Open
Abstract
Left bundle branch block (LBBB) is a frequent finding in patients with heart failure (HF), particularly in those with dilated cardiomyopathy (DCM). LBBB has been commonly described as a consequence of DCM development. However, a total recovery of left ventricular (LV) function after cardiac resynchronization therapy (CRT), observed in patients with LBBB and DCM, has led to increasing acknowledgement of LBBB-induced dilated cardiomyopathy (LBBB-iDCM) as a specific pathological entity. Its recognition has important clinical implications, as LBBB-iDCM patients may benefit from an early CRT strategy rather than medical HF therapy only. At present, there are no definitive diagnostic criteria enabling the universal identification of LBBB-iDCM, and no defined therapeutic approach in this subgroup of patients. This review compiles the main findings about LBBB-iDCM pathophysiology and the current proposed diagnostic criteria and therapeutic approach.
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Affiliation(s)
- Catarina Amaral Marques
- Faculty of Medicine - University of Porto, Porto, Portugal; Department of Cardiology, Centro Hospitalar Universitário São João, Porto, Portugal.
| | | | - Elisabete Martins
- Faculty of Medicine - University of Porto, Porto, Portugal; Department of Cardiology, Centro Hospitalar Universitário São João, Porto, Portugal
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Kodama N, Nakagawa M, Ishii Y, Yufu K, Yamauchi S, Yamamoto E, Miyoshi M, Abe I, Kondo H, Fukui A, Satoh H, Akiyoshi K, Fukuda T, Shinohara T, Teshima Y, Takahashi N. R-R' interval in the left bundle branch block predicts long-term outcomes after cardiac resynchronization therapy by estimating greater mechanical dyssynchrony and viable myocardium. Heart Rhythm 2024; 21:436-444. [PMID: 38154602 DOI: 10.1016/j.hrthm.2023.12.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 12/20/2023] [Accepted: 12/20/2023] [Indexed: 12/30/2023]
Abstract
BACKGROUND Typical left bundle branch block (LBBB) shows 2 peaks of the R wave, which reflect activation reaching the interventricular septum (R) and posterolateral wall (R') sequentially. OBJECTIVE The purpose of this study was to investigate the relationship among R-R' interval (RR'), mechanical dyssynchrony, extent of viable myocardium, and long-term outcomes in cardiac resynchronization therapy (CRT) candidates. METHODS The study enrolled 49 patients (34 men; mean age: 69 ± 11 years) with LBBB who received CRT. The LBBB definition used requires the presence of mid-QRS notching in leads V1, V2, V5, V6, I, and aVL. Baseline evaluations were QRS duration (QRSd) and RR' measured from the 12-lead electrocardiogram; eyeball dyssynchrony (apical rocking and septal flash) and opposing-wall delay by speckle tracking from echocardiography, and extent of viable myocardium assessed by thallium-201 single-photon emission computed tomography. Primary outcomes included the combination of all-cause death and heart failure-related hospitalization. RESULTS RR' predicted volumetric response better than QRSd (area under the curve 0.73 vs 0.67, respectively). The long RR' group (≥48 ms) revealed more frequent eyeball dyssynchrony and significantly greater radial (SL) and circumferential dyssynchrony (AP and SL) and %viable segment than the short RR' group. In multivariate regression analysis, only RR' ≥48 ms was independently associated with higher event-free survival rates following CRT (hazard ratio 0.21; P = .014). CONCLUSION These findings suggest that RR' in complete LBBB was associated with mechanical dyssynchrony, extent of viable myocardium, and long-term outcomes following CRT.
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Affiliation(s)
- Nozomi Kodama
- Department of Cardiology and Clinical Examination and Diagnosis, Faculty of Medicine, Oita University, Oita, Japan
| | - Mikiko Nakagawa
- Department of Cardiology and Clinical Examination and Diagnosis, Faculty of Medicine, Oita University, Oita, Japan.
| | - Yumi Ishii
- Department of Cardiology and Clinical Examination and Diagnosis, Faculty of Medicine, Oita University, Oita, Japan
| | - Kunio Yufu
- Department of Cardiology and Clinical Examination and Diagnosis, Faculty of Medicine, Oita University, Oita, Japan
| | - Syuichiro Yamauchi
- Department of Cardiology and Clinical Examination and Diagnosis, Faculty of Medicine, Oita University, Oita, Japan
| | - Ena Yamamoto
- Department of Cardiology and Clinical Examination and Diagnosis, Faculty of Medicine, Oita University, Oita, Japan
| | - Miho Miyoshi
- Department of Cardiology and Clinical Examination and Diagnosis, Faculty of Medicine, Oita University, Oita, Japan
| | - Ichitaro Abe
- Department of Cardiology and Clinical Examination and Diagnosis, Faculty of Medicine, Oita University, Oita, Japan
| | - Hidekazu Kondo
- Department of Cardiology and Clinical Examination and Diagnosis, Faculty of Medicine, Oita University, Oita, Japan
| | - Akira Fukui
- Department of Cardiology and Clinical Examination and Diagnosis, Faculty of Medicine, Oita University, Oita, Japan
| | - Hideki Satoh
- Department of Cardiology and Clinical Examination and Diagnosis, Faculty of Medicine, Oita University, Oita, Japan
| | - Kumiko Akiyoshi
- Department of Cardiology and Clinical Examination and Diagnosis, Faculty of Medicine, Oita University, Oita, Japan
| | - Tomoko Fukuda
- Department of Cardiology and Clinical Examination and Diagnosis, Faculty of Medicine, Oita University, Oita, Japan
| | - Tetsuji Shinohara
- Department of Cardiology and Clinical Examination and Diagnosis, Faculty of Medicine, Oita University, Oita, Japan
| | - Yasushi Teshima
- Department of Cardiology and Clinical Examination and Diagnosis, Faculty of Medicine, Oita University, Oita, Japan
| | - Naohiko Takahashi
- Department of Cardiology and Clinical Examination and Diagnosis, Faculty of Medicine, Oita University, Oita, Japan
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Wang CL, Wu LS, Wu CT, Yeh YH, Cheng YW, Yen KC, Chan YH, Chuang C, Kuo CT, Chu PH. Clinical significance of regional constructive and wasted work in patients receiving cardiac resynchronization therapy. Front Cardiovasc Med 2024; 11:1301140. [PMID: 38510200 PMCID: PMC10950977 DOI: 10.3389/fcvm.2024.1301140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Accepted: 02/22/2024] [Indexed: 03/22/2024] Open
Abstract
Background Previous studies have shown that global constructive work (CW) and wasted work (WW) predict response to cardiac resynchronization therapy (CRT). This study evaluated the predictive value of regional CW and WW for reverse remodeling and clinical outcomes after CRT. Methods We performed a prospective study involving 134 CRT candidates with left bundle branch block and left ventricular ejection fraction ≤35%. Global and regional CW and WW were calculated using pressure-strain loop analysis. CRT response was defined by reverse remodeling as a reduction of ≥15% in left ventricular end-systolic volume after six months. Results At six-month follow-up, 92 (69%) patients responded to CRT. Of the regional CW and WW measures, lateral wall (LW) CW and septal WW were most strongly and significantly correlated with reverse remodeling. At multivariate analysis, LW CW and septal WW were both independent determinants of reverse remodeling. When LW CW and septal WW were included in the model, global CW and WW were not independently associated with reverse remodeling. LW CW and septal WW predicted reverse remodeling with an area under the curve (AUC) of 0.783 (95% CI: 0.700-0.866) and 0.737 (95% CI: 0.644-0.831), respectively. Using both variables increased the AUC to 0.832 (95% CI: 0.755-0.908). Both LW CW ≤878 mmHg% (HR 2.01; 95% CI: 1.07-3.79) and septal WW ≤181 mmHg% (HR 2.60; 95% CI: 1.38-4.90) were significant predictors of combined death and HF hospitalization at two-year follow-up. Conclusion LW CW and septal WW before CRT are important determinants of reverse remodeling and clinical outcomes.
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Affiliation(s)
- Chun-Li Wang
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Linkou, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Lung-Sheng Wu
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Linkou, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chia-Tung Wu
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Linkou, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Yung-Hsin Yeh
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Linkou, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Yu-Wen Cheng
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Linkou, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Kun-Chi Yen
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Linkou, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Yi-Hsin Chan
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Linkou, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Microscopy Core Laboratory, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Chi Chuang
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Linkou, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Division of Cardiology, Department of Internal Medicine, New Taipei City Municipal Tucheng Hospital, New Taipei City, Taiwan
| | - Chi-Tai Kuo
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Linkou, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Pao-Hsien Chu
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Linkou, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
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Mao Y, Duchenne J, Yang Y, Garweg C, Yang Y, Sheng X, Zhang J, Ye Y, Wang M, Paton MF, Puvrez A, Vöros G, Ma M, Fu G, Voigt JU. Left bundle branch pacing better preserves ventricular mechanical synchrony than right ventricular pacing: a two-centre study. Eur Heart J Cardiovasc Imaging 2024; 25:328-336. [PMID: 37933672 DOI: 10.1093/ehjci/jead296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 10/10/2023] [Accepted: 10/23/2023] [Indexed: 11/08/2023] Open
Abstract
AIMS Left bundle branch pacing (LBBP) has been shown to better maintain electrical synchrony compared with right ventricular pacing (RVP), but little is known about its impact on mechanical synchrony. This study investigates whether LBBP better preserves left ventricular (LV) mechanical synchronicity and function compared with RVP. METHODS AND RESULTS Sixty patients with pacing indication for bradycardia were included: LBBP (n = 31) and RVP (n = 29). Echocardiography was performed before and shortly after pacemaker implantation and at 1-year follow-up. The lateral wall-septal wall (LW-SW) work difference was used as a measure of mechanical dyssynchrony. Septal flash, apical rocking, and septal strain patterns were also assessed. At baseline, LW-SW work difference was small and similar in two groups. SW was markedly decreased, while LW work remained mostly unchanged in RVP, resulting in a larger LW-SW work difference compared with LBBP (1253 ± 687 mmHg·% vs. 439 ± 408 mmHg·%, P < 0.01) at last follow-up. In addition, RVP more often induced septal flash or apical rocking and resulted in more advanced strain patterns compared with LBBP. At 1 year follow-up, LV ejection fraction (EF) and global longitudinal strain (GLS) were more decreased in RVP compared with LBBP (ΔLVEF: -7.4 ± 7.0% vs. 0.3 ± 4.1%; ΔLVGLS: -4.8 ± 4.0% vs. -1.4 ± 2.5%, both P < 0.01). In addition, ΔLW-SW work difference was independently correlated with LV adverse remodelling (r = 0.42, P < 0.01) and LV dysfunction (ΔLVEF: r = -0.61, P < 0.01 and ΔLVGLS: r = -0.38, P = 0.02). CONCLUSION LBBP causes less LV mechanical dyssynchrony than RVP as it preserves a more physiologic electrical conduction. As a consequence, LBBP appears to preserve LV function better than RVP.
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Affiliation(s)
- Yankai Mao
- Department of Diagnostic Ultrasound and Echocardiography, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Department of Cardiovascular Sciences, KU Leuven, Herestraat 49, Leuven 3000, Belgium
| | - Jürgen Duchenne
- Department of Cardiovascular Sciences, KU Leuven, Herestraat 49, Leuven 3000, Belgium
| | - Yuan Yang
- Department of Diagnostic Ultrasound and Echocardiography, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Christophe Garweg
- Department of Cardiovascular Sciences, KU Leuven, Herestraat 49, Leuven 3000, Belgium
- Department of Cardiovascular Diseases, University Hospitals Leuven, Herestraat 49, Leuven 3000, Belgium
| | - Ying Yang
- Department of Cardiology, Key Laboratory of Cardiovascular Intervention and Regenerative Medicine of Zhejiang Province, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, East Qingchun Road 3, Hangzhou 310016, China
| | - Xia Sheng
- Department of Cardiology, Key Laboratory of Cardiovascular Intervention and Regenerative Medicine of Zhejiang Province, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, East Qingchun Road 3, Hangzhou 310016, China
| | - Jiefang Zhang
- Department of Cardiology, Key Laboratory of Cardiovascular Intervention and Regenerative Medicine of Zhejiang Province, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, East Qingchun Road 3, Hangzhou 310016, China
| | - Yang Ye
- Department of Cardiology, Key Laboratory of Cardiovascular Intervention and Regenerative Medicine of Zhejiang Province, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, East Qingchun Road 3, Hangzhou 310016, China
| | - Min Wang
- Department of Cardiology, Key Laboratory of Cardiovascular Intervention and Regenerative Medicine of Zhejiang Province, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, East Qingchun Road 3, Hangzhou 310016, China
| | - Maria F Paton
- Department of Cardiovascular Sciences, KU Leuven, Herestraat 49, Leuven 3000, Belgium
- Leeds Institute of Cardiovascular and Metabolic Medicine, Multidisciplinary Cardiovascular Research Centre, University of Leeds, Leeds, UK
- Leeds Cardiovascular Clinical Research Facility, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Alexis Puvrez
- Department of Cardiovascular Sciences, KU Leuven, Herestraat 49, Leuven 3000, Belgium
- Department of Cardiovascular Diseases, University Hospitals Leuven, Herestraat 49, Leuven 3000, Belgium
| | - Gabor Vöros
- Department of Cardiovascular Sciences, KU Leuven, Herestraat 49, Leuven 3000, Belgium
- Department of Cardiovascular Diseases, University Hospitals Leuven, Herestraat 49, Leuven 3000, Belgium
| | - Mingming Ma
- Department of Diagnostic Ultrasound and Echocardiography, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Guosheng Fu
- Department of Cardiology, Key Laboratory of Cardiovascular Intervention and Regenerative Medicine of Zhejiang Province, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, East Qingchun Road 3, Hangzhou 310016, China
| | - Jens-Uwe Voigt
- Department of Cardiovascular Sciences, KU Leuven, Herestraat 49, Leuven 3000, Belgium
- Department of Cardiovascular Diseases, University Hospitals Leuven, Herestraat 49, Leuven 3000, Belgium
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9
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Dutta A, Alqabbani RRM, Hagendorff A, Tayal B. Understanding the Application of Mechanical Dyssynchrony in Patients with Heart Failure Considered for CRT. J Cardiovasc Dev Dis 2024; 11:64. [PMID: 38392278 PMCID: PMC10888548 DOI: 10.3390/jcdd11020064] [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: 11/15/2023] [Revised: 01/16/2024] [Accepted: 01/23/2024] [Indexed: 02/24/2024] Open
Abstract
Over the past two decades of CRT use, the failure rate has remained around 30-35%, despite several updates in the guidelines based on the understanding from multiple trials. This review article summarizes the role of mechanical dyssynchrony in the selection of heart failure patients for cardiac resynchronization therapy. Understanding the application of mechanical dyssynchrony has also evolved during these past two decades. There is no role of lone mechanical dyssynchrony in the patient selection for CRT. However, mechanical dyssynchrony can complement the electrocardiogram and clinical criteria and improve patient selection by reducing the failure rate. An oversimplified approach to mechanical dyssynchrony assessment, such as just estimating time-to-peak delays between segments, should not be used. Instead, methods that can identify the underlying pathophysiology of HF and are representative of a substrate to CRT should be applied.
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Affiliation(s)
- Abhishek Dutta
- Department of Cardiology, Nazareth Hospital, Philadelphia, PA 19020, USA
| | - Rakan Radwan M Alqabbani
- Department of Internal Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH 44106, USA
| | - Andreas Hagendorff
- Department of Cardiology, Leipzig University Hospital, 04103 Leipzig, Germany
| | - Bhupendar Tayal
- Harrington and Heart and Vascular Center, University Hospitals Cleveland Medical Center, Cleveland, OH 44106, USA
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10
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Ahmed MA, Gercek M, Sommer P, Rudolph V, Dumitrescu D, Faber L, Fox H. Echocardiographic mechanical dyssynchrony predicts long-term mortality in patients with cardiac resynchronisation therapy. Int J Cardiovasc Imaging 2024; 40:35-43. [PMID: 37819382 PMCID: PMC10774169 DOI: 10.1007/s10554-023-02972-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 09/24/2023] [Indexed: 10/13/2023]
Abstract
Cardiac resynchronisation therapy (CRT) is an established treatment for patients with symptomatic heart failure with reduced left ventricular ejection fraction (LVEF ≤ 35%; HFrEF) and conduction disturbances (QRS duration ≥ 130 ms). The presence of mechanical dyssynchrony (MD) on echocardiography has been hypothesised to be of predictive value in determining indication for CRT. This study investigated the impact of MD (apical rocking [AR] and septal flash [SF]) on long-term survival in CRT recipients. HFrEF patients (n = 425; mean age 63.0 ± 10.6 years, 72.3% male, 60.7% non-ischaemic aetiology) with a guideline-derived indication for CRT underwent device implantation. MD markers were determined at baseline and after a mean follow-up of 11.5 ± 8.0 months; long-term survival was also determined. AR and/or SF were present in 307 (72.2%) participants at baseline. During post-CRT follow-up, AR and/or SF disappeared in 256 (83.4%) patients. Overall mean survival was 95.9 ± 52.9 months, longer in women than in men (109.1 ± 52.4 vs. 90.9 ± 52.4 months; p < 0.001) and in younger (< 60 years) versus older patients (110.6 ± 53.7 vs. 88.6 ± 51.1 months; p < 0.001). Patients with versus without MD markers at baseline generally survived for longer (106.2 ± 52.0 vs. 68.9 ± 45.4 months; p < 0.001), and survival was best in patients with resolved versus persisting MD (111.6 ± 51.2 vs. 79.7 ± 47.6 months p < 0.001). Age and MD at baseline were strong predictors of long-term survival in HFrEF patients undergoing CRT on multivariate analysis. Novel echocardiography MD parameters in HFrEF CRT recipients predicted long-term mediated better outcome, and survival improved further when AR and/or SF disappear after CRT implantation.
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Affiliation(s)
- Mohamed Abdelbaset Ahmed
- Clinic for General and Interventional Cardiology/Angiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Georgstr. 11, D-32545, Bad Oeynhausen, Germany
| | - Muhammed Gercek
- Clinic for General and Interventional Cardiology/Angiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Georgstr. 11, D-32545, Bad Oeynhausen, Germany
| | - Philipp Sommer
- Clinic for Electrophysiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Georgstr. 11, D-32545, Bad Oeynhausen, Germany
| | - Volker Rudolph
- Clinic for General and Interventional Cardiology/Angiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Georgstr. 11, D-32545, Bad Oeynhausen, Germany
- Heart Failure Department, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Georgstr. 11, D-32545, Bad Oeynhausen, Germany
| | - Daniel Dumitrescu
- Clinic for General and Interventional Cardiology/Angiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Georgstr. 11, D-32545, Bad Oeynhausen, Germany
- Heart Failure Department, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Georgstr. 11, D-32545, Bad Oeynhausen, Germany
| | - Lothar Faber
- Clinic for General and Interventional Cardiology/Angiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Georgstr. 11, D-32545, Bad Oeynhausen, Germany
| | - Henrik Fox
- Clinic for Thoracic and Cardiovascular Surgery, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Georgstr. 11, D-32545, Bad Oeynhausen, Germany.
- Heart Failure Department, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Georgstr. 11, D-32545, Bad Oeynhausen, Germany.
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11
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Burke GM, Popma JJ, Chang JD. Heart Failure after Transcatheter Aortic Valve Implantation: Application of the Most Impactful Strain Imaging Techniques. CASE (PHILADELPHIA, PA.) 2024; 8:4-10. [PMID: 38264618 PMCID: PMC10801808 DOI: 10.1016/j.case.2023.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/25/2024]
Abstract
•LBBB is the most common TAVI-induced conduction abnormality. •Strain imaging can assist with determining the etiology of heart failure after TAVI. •Strain imaging can help predict response to CRT.
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Affiliation(s)
- Gordon M. Burke
- VA Boston Healthcare System, Cardiology Section 111CA, West Roxbury, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Jeffrey J. Popma
- Harvard Medical School, Boston, Massachusetts
- Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - James D. Chang
- Harvard Medical School, Boston, Massachusetts
- Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
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12
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Højgaard EV, Philbert BT, Linde JJ, Winsløw UC, Svendsen JH, Vinther M, Risum N. Efficacy on resynchronization and longitudinal contractile function comparing His-bundle pacing with conventional biventricular pacing: a substudy to the His-alternative study. Eur Heart J Cardiovasc Imaging 2023; 25:66-74. [PMID: 37490036 DOI: 10.1093/ehjci/jead181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 03/30/2023] [Accepted: 07/15/2023] [Indexed: 07/26/2023] Open
Abstract
AIMS His-bundle pacing has emerged as a novel method to deliver cardiac resynchronization therapy (CRT). However, there are no data comparing conventional biventricular (BiV)-CRT with His-CRT with regard to effects on mechanical dyssynchrony and longitudinal contractile function. METHODS AND RESULTS Patients with symptomatic heart failure, left ventricular ejection fraction ≤ 35%, and left bundle branch block (LBBB) by strict ECG criteria were randomized 1:1 to His-CRT or BiV-CRT. Two-dimensional strain echocardiography was performed prior to CRT implantation and at 6 months after implantation. Differences in changes in mechanical dyssynchrony (standard deviation of time-to-peak in 12 midventricular and basal segments) and regional longitudinal strain in the six left ventricular walls were compared between the BiV-CRT and His-CRT groups.In the on-treatment analysis, 31 received BiV-CRT and 19 His-CRT. In both groups, mechanical dyssynchrony was significantly reduced after 6 months [BiV group from 120 ms (±45) to 63 ms (±22), P < 0.001, and His group from 116 ms (±54) to 49 ms (±11), P < 0.001] but no significant differences in changes could be demonstrated between groups [-9.0 ms (-36; 18), P = 0.50]. Global longitudinal strain (GLS) improved in both groups [BiV group from -9.1% (±2.7) to -10.7% (±2.6), P = 0.02, and His group from -8.6% (±2.1) to -11.1% (±2.0), P < 0.001], but no significant differences in changes could be demonstrated from baseline to follow-up [-0.9% (-2.4; -0.6), P = 0.25] between groups. There were no regional differences between groups. CONCLUSION In heart failure, patients with LBBB, BiV-CRT, and His-CRT have comparable effects with regard to improvements in mechanical dyssynchrony and longitudinal contractile function.
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Affiliation(s)
- E V Højgaard
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - B T Philbert
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - J J Linde
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - U C Winsløw
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - J H Svendsen
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - M Vinther
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - N Risum
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
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13
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Stankovic I, Voigt JU, Burri H, Muraru D, Sade LE, Haugaa KH, Lumens J, Biffi M, Dacher JN, Marsan NA, Bakelants E, Manisty C, Dweck MR, Smiseth OA, Donal E. Imaging in patients with cardiovascular implantable electronic devices: part 2-imaging after device implantation. A clinical consensus statement of the European Association of Cardiovascular Imaging (EACVI) and the European Heart Rhythm Association (EHRA) of the ESC. Eur Heart J Cardiovasc Imaging 2023; 25:e33-e54. [PMID: 37861420 DOI: 10.1093/ehjci/jead273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2023] [Revised: 10/15/2023] [Accepted: 10/15/2023] [Indexed: 10/21/2023] Open
Abstract
Cardiac implantable electronic devices (CIEDs) improve quality of life and prolong survival, but there are additional considerations for cardiovascular imaging after implantation-both for standard indications and for diagnosing and guiding management of device-related complications. This clinical consensus statement (part 2) from the European Association of Cardiovascular Imaging, in collaboration with the European Heart Rhythm Association, provides comprehensive, up-to-date, and evidence-based guidance to cardiologists, cardiac imagers, and pacing specialists regarding the use of imaging in patients after implantation of conventional pacemakers, cardioverter defibrillators, and cardiac resynchronization therapy (CRT) devices. The document summarizes the existing evidence regarding the role and optimal use of various cardiac imaging modalities in patients with suspected CIED-related complications and also discusses CRT optimization, the safety of magnetic resonance imaging in CIED carriers, and describes the role of chest radiography in assessing CIED type, position, and complications. The role of imaging before and during CIED implantation is discussed in a companion document (part 1).
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Affiliation(s)
- Ivan Stankovic
- Clinical Hospital Centre Zemun, Department of Cardiology, Faculty of Medicine, University of Belgrade, Vukova 9, 11080 Belgrade, Serbia
| | - Jens-Uwe Voigt
- Department of Cardiovascular Diseases, University Hospitals Leuven/Department of Cardiovascular Sciences, Catholic University of Leuven, Herestraat 49, 3000 Leuven, Belgium
| | - Haran Burri
- Cardiac Pacing Unit, Cardiology Department, University Hospital of Geneva, Geneva, Switzerland
| | - Denisa Muraru
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Milan, Italy
| | - Leyla Elif Sade
- University of Pittsburgh Medical Center, Heart and Vascular Institute, Pittsburgh, PA, USA
- University of Baskent, Department of Cardiology, Ankara, Turkey
| | - Kristina Hermann Haugaa
- ProCardio Center for Innovation, Department of Cardiology, Oslo University Hospital, Rikshospitalet, Norway
- Faculty of Medicine, Karolinska Institutet and Cardiovascular Division, Karolinska University Hospital, Stockholm, Sweden
| | - Joost Lumens
- Cardiovascular Research Center Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - Mauro Biffi
- Department of Cardiology, IRCCS, Azienda Ospedaliero Universitaria Di Bologna, Policlinico Di S.Orsola, Bologna, Italy
| | - Jean-Nicolas Dacher
- Department of Radiology, Normandie University, UNIROUEN, INSERM U1096-Rouen University Hospital, F 76000 Rouen, France
| | - Nina Ajmone Marsan
- Department of Cardiology, Heart and Lung Center, Leiden University Medical Center, The Netherlands
| | - Elise Bakelants
- Cardiac Pacing Unit, Cardiology Department, University Hospital of Geneva, Geneva, Switzerland
| | - Charlotte Manisty
- Department of Cardiovascular Imaging, Barts Heart Centre, Barts Health NHS Trust, London, UK
- Institute of Cardiovascular Science, University College London, London, UK
| | - Marc R Dweck
- Centre for Cardiovascular Science, University of Edinburgh, Little France Crescent, Edinburgh EH16 4SB, UK
| | - Otto A Smiseth
- Institute for Surgical Research, Oslo University Hospital and University of Oslo, Oslo, Norway
| | - Erwan Donal
- University of Rennes, CHU Rennes, Inserm, LTSI-UMR 1099, Rennes, France
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14
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Donal E, Neveu A, Stankovic I. Assessing left ventricular myocardial work and the risk for malignant arrhythmias: does it work? Eur Heart J Cardiovasc Imaging 2023; 25:37-38. [PMID: 37552792 DOI: 10.1093/ehjci/jead198] [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: 08/01/2023] [Accepted: 08/03/2023] [Indexed: 08/10/2023] Open
Affiliation(s)
- Erwan Donal
- Service de Cardiologie, Hôpital Pontchaillou, CHU Rennes, F-35033 Rennes, France
| | - Antoine Neveu
- Service de Cardiologie, Hôpital Pontchaillou, CHU Rennes, F-35033 Rennes, France
| | - Ivan Stankovic
- Clinical Hospital Centre Zemun, Faculty of Medicine, University of Belgrade, Serbia
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15
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Stankovic I, Voigt JU, Burri H, Muraru D, Sade LE, Haugaa KH, Lumens J, Biffi M, Dacher JN, Marsan NA, Bakelants E, Manisty C, Dweck MR, Smiseth OA, Donal E. Imaging in patients with cardiovascular implantable electronic devices: part 1-imaging before and during device implantation. A clinical consensus statement of the European Association of Cardiovascular Imaging (EACVI) and the European Heart Rhythm Association (EHRA) of the ESC. Eur Heart J Cardiovasc Imaging 2023; 25:e1-e32. [PMID: 37861372 DOI: 10.1093/ehjci/jead272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2023] [Revised: 10/15/2023] [Accepted: 10/15/2023] [Indexed: 10/21/2023] Open
Abstract
More than 500 000 cardiovascular implantable electronic devices (CIEDs) are implanted in the European Society of Cardiology countries each year. The role of cardiovascular imaging in patients being considered for CIED is distinctly different from imaging in CIED recipients. In the former group, imaging can help identify specific or potentially reversible causes of heart block, the underlying tissue characteristics associated with malignant arrhythmias, and the mechanical consequences of conduction delays and can also aid challenging lead placements. On the other hand, cardiovascular imaging is required in CIED recipients for standard indications and to assess the response to device implantation, to diagnose immediate and delayed complications after implantation, and to guide device optimization. The present clinical consensus statement (Part 1) from the European Association of Cardiovascular Imaging, in collaboration with the European Heart Rhythm Association, provides comprehensive, up-to-date, and evidence-based guidance to cardiologists, cardiac imagers, and pacing specialists regarding the use of imaging in patients undergoing implantation of conventional pacemakers, cardioverter defibrillators, and resynchronization therapy devices. The document summarizes the existing evidence regarding the use of imaging in patient selection and during the implantation procedure and also underlines gaps in evidence in the field. The role of imaging after CIED implantation is discussed in the second document (Part 2).
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Affiliation(s)
- Ivan Stankovic
- Clinical Hospital Centre Zemun, Department of Cardiology, Faculty of Medicine, University of Belgrade, Vukova 9, 11080 Belgrade, Serbia
| | - Jens-Uwe Voigt
- Department of Cardiovascular Diseases, University Hospitals Leuven/Department of Cardiovascular Sciences, Catholic University of Leuven, Herestraat 49, Leuven 3000, Belgium
| | - Haran Burri
- Cardiac Pacing Unit, Cardiology Department, University Hospital of Geneva, Geneva, Switzerland
| | - Denisa Muraru
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Milan, Italy
| | - Leyla Elif Sade
- University of Pittsburgh Medical Center, Heart and Vascular Institute, Pittsburgh, PA, USA
- Department of Cardiology, University of Baskent, Ankara, Turkey
| | - Kristina Hermann Haugaa
- ProCardio Center for Innovation, Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
- Faculty of Medicine Karolinska Institutet AND Cardiovascular Division, Karolinska University Hospital, StockholmSweden
| | - Joost Lumens
- Cardiovascular Research Center Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - Mauro Biffi
- Department of Cardiology, IRCCS, Azienda Ospedaliero Universitaria Di Bologna, Policlinico Di S.Orsola, Bologna, Italy
| | - Jean-Nicolas Dacher
- Department of Radiology, Normandie University, UNIROUEN, INSERM U1096 - Rouen University Hospital, F 76000 Rouen, France
| | - Nina Ajmone Marsan
- Department of Cardiology, Heart and Lung Center, Leiden University Medical Center, Leiden, The Netherlands
| | - Elise Bakelants
- Cardiac Pacing Unit, Cardiology Department, University Hospital of Geneva, Geneva, Switzerland
| | - Charlotte Manisty
- Department of Cardiovascular Imaging, Barts Heart Centre, Barts Health NHS Trust, London, UK
- Institute of Cardiovascular Science, University College London, London, UK
| | - Marc R Dweck
- Centre for Cardiovascular Science, University of Edinburgh, Little France Crescent, Edinburgh EH16 4SB, United Kingdom
| | - Otto A Smiseth
- Institute for Surgical Research, Oslo University Hospital and University of Oslo, Oslo, Norway
| | - Erwan Donal
- University of Rennes, CHU Rennes, Inserm, LTSI-UMR 1099, Rennes, France
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16
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Presume J, Paiva MS, Guerreiro S, Ribeiras R. Parameters of the mitral apparatus in patients with ischemic and nonischemic dilated cardiomyopathy. J Int Med Res 2023; 51:3000605231218645. [PMID: 38150557 PMCID: PMC10754024 DOI: 10.1177/03000605231218645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 11/10/2023] [Indexed: 12/29/2023] Open
Abstract
The mitral valve apparatus is a complex structure consisting of several coordinating components: the annulus, two leaflets, the chordae tendineae, and the papillary muscles. Due to the intricate interplay between the mitral valve and the left ventricle, a disease of the latter may influence the normal function of the former. As a consequence, valve insufficiency may arise despite the absence of organic valve disease. This is designated as functional or secondary mitral regurgitation, and it arises from a series of distortions to the valve components. This narrative review describes the normal anatomy and the pathophysiology behind the mitral valve changes in ischemic and non-ischemic dilated cardiomyopathies. It also explains the value of a complete multiparametric assessment of this structure. Not only must an assessment include quantitative measures of regurgitation, but also various anatomical parameters from the mitral apparatus and left ventricle, since they carry prognostic value and are predictors of mitral valve repair success and durability.
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Affiliation(s)
- João Presume
- Cardiology Department, Hospital de Santa Cruz, Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal
- Comprehensive Health Research Centre, NOVA Medical School, Universidade Nova de Lisboa, Lisbon, Portugal
| | - Mariana S Paiva
- Cardiology Department, Hospital de Santa Cruz, Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal
| | - Sara Guerreiro
- Cardiology Department, Hospital de Santa Cruz, Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal
| | - Regina Ribeiras
- Cardiology Department, Hospital de Santa Cruz, Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal
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17
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Kodsi M, Makarious D, Gan GC, Choudhary P, Thomas L. Cardiac reverse remodelling by imaging parameters with recent changes to guideline medical therapy in heart failure. ESC Heart Fail 2023; 10:3258-3275. [PMID: 37871982 PMCID: PMC10682888 DOI: 10.1002/ehf2.14555] [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: 03/28/2023] [Revised: 08/29/2023] [Accepted: 09/20/2023] [Indexed: 10/25/2023] Open
Abstract
Recently established heart failure therapies, including sodium glucose co-transporter 2 inhibitors, angiotensin-neprilysin inhibitors, and cardiac resynchronization therapy, have led to both clinical and structural improvements. Reverse remodelling describes the structural and functional responses to therapy and has been shown to correlate with patients' clinical response, acting as a biomarker for treatment success. The introduction of these new therapeutic agents in addition to advances in non-invasive cardiac imaging has led to an expansion in the evaluation and the validation of cardiac reverse remodelling. Methods including volumetric changes as well as strain and myocardial work have all been shown to be non-invasive end-points of reverse remodelling, correlating with clinical outcomes. Our review summarizes the current available evidence on reverse remodelling in heart failure by the non-invasive cardiac imaging techniques, in particular transthoracic echocardiography.
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Affiliation(s)
- Matthew Kodsi
- Department of CardiologyWestmead HospitalSydneyAustralia
| | - David Makarious
- Department of CardiologyWestmead HospitalSydneyAustralia
- Westmead Clinical School, Westmead HospitalUniversity of SydneySydneyAustralia
| | - Gary C.H. Gan
- Department of CardiologyWestmead HospitalSydneyAustralia
| | - Preeti Choudhary
- Department of CardiologyWestmead HospitalSydneyAustralia
- Westmead Clinical School, Westmead HospitalUniversity of SydneySydneyAustralia
| | - Liza Thomas
- Department of CardiologyWestmead HospitalSydneyAustralia
- Westmead Clinical School, Westmead HospitalUniversity of SydneySydneyAustralia
- South West clinical SchoolUniversity of New South WalesSydneyAustralia
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18
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Larsen CK, Smiseth OA, Duchenne J, Galli E, Aalen JM, Lederlin M, Bogaert J, Kongsgaard E, Linde C, Penicka M, Donal E, Voigt JU, Hopp E. Cardiac Magnetic Resonance Identifies Responders to Cardiac Resynchronization Therapy with an Assessment of Septal Scar and Left Ventricular Dyssynchrony. J Clin Med 2023; 12:7182. [PMID: 38002795 PMCID: PMC10672328 DOI: 10.3390/jcm12227182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 11/15/2023] [Accepted: 11/18/2023] [Indexed: 11/26/2023] Open
Abstract
Background: The response to cardiac resynchronization therapy (CRT) depends on septal viability and correction of abnormal septal motion. This study investigates if cardiac magnetic resonance (CMR) as a single modality can identify CRT responders with combined imaging of pathological septal motion (septal flash) and septal scar. Methods: In a prospective, multicenter, observational study of 136 CRT recipients, septal scar was assessed using late gadolinium enhancement (LGE) (n = 127) and septal flash visually from cine CMR sequences. The primary endpoint was CRT response, defined as ≥15% reduction in LV end-systolic volume with echocardiography after 6 months. The secondary endpoint was heart transplantation or death of any cause assessed after 39 ± 13 months. Results: Septal scar and septal flash were independent predictors of CRT response in multivariable analysis (both p < 0.001), while QRS duration and morphology were not. The combined approach of septal scar and septal flash predicted CRT response with an area under the curve of 0.86 (95% confidence interval (CI): 0.78-0.94) and was a strong predictor of long-term survival without heart transplantation (hazard ratio 0.27, 95% CI: 0.10-0.79). The accuracy of the approach was similar in the subgroup with intermediate (130-150 ms) QRS duration. The combined approach was superior to septal scar and septal flash alone (p < 0.01). Conclusions: The combined assessment of septal scar and septal flash using CMR as a single-image modality identifies CRT responders with high accuracy and predicts long-term survival.
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Affiliation(s)
- Camilla Kjellstad Larsen
- Institute for Surgical Research and Department of Cardiology, Oslo University Hospital, 0027 Oslo, Norway; (C.K.L.); (O.A.S.); (J.M.A.)
- Institute of Clinical Medicine, University of Oslo, 0316 Oslo, Norway
| | - Otto A. Smiseth
- Institute for Surgical Research and Department of Cardiology, Oslo University Hospital, 0027 Oslo, Norway; (C.K.L.); (O.A.S.); (J.M.A.)
- Institute of Clinical Medicine, University of Oslo, 0316 Oslo, Norway
| | - Jürgen Duchenne
- Department of Cardiovascular Diseases, University Hospitals Leuven, 3000 Leuven, Belgium (J.-U.V.)
- Department of Cardiovascular Sciences, KU Leuven—University of Leuven, 3000 Leuven, Belgium
| | - Elena Galli
- Department of Cardiology, University Hospital of Rennes, 35000 Rennes, France; (E.G.); (E.D.)
| | - John Moene Aalen
- Institute for Surgical Research and Department of Cardiology, Oslo University Hospital, 0027 Oslo, Norway; (C.K.L.); (O.A.S.); (J.M.A.)
- Institute of Clinical Medicine, University of Oslo, 0316 Oslo, Norway
| | - Mathieu Lederlin
- Department of Radiology, University Hospital of Rennes, 35000 Rennes, France;
| | - Jan Bogaert
- Department of Radiology, University Hospitals Leuven, 3000 Leuven, Belgium;
| | - Erik Kongsgaard
- Department of Cardiology, Oslo University Hospital, 0027 Oslo, Norway;
| | - Cecilia Linde
- Department of Cardiology, Karolinska University Hospital, 171 64 Solna, Sweden;
| | | | - Erwan Donal
- Department of Cardiology, University Hospital of Rennes, 35000 Rennes, France; (E.G.); (E.D.)
| | - Jens-Uwe Voigt
- Department of Cardiovascular Diseases, University Hospitals Leuven, 3000 Leuven, Belgium (J.-U.V.)
- Department of Cardiovascular Sciences, KU Leuven—University of Leuven, 3000 Leuven, Belgium
| | - Einar Hopp
- Division of Radiology and Nuclear Medicine, Oslo University Hospital, 0027 Oslo, Norway
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Manganaro R, Cusmà-Piccione M, Carerj S, Licordari R, Khandheria BK, Zito C. Echocardiographic Patterns of Abnormal Septal Motion: Beyond Myocardial Ischemia. J Am Soc Echocardiogr 2023; 36:1140-1153. [PMID: 37574150 DOI: 10.1016/j.echo.2023.08.003] [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: 03/22/2022] [Revised: 07/25/2023] [Accepted: 08/04/2023] [Indexed: 08/15/2023]
Abstract
Abnormal septal motion (ASM), which often is associated with myocardial ischemia, is also observed in other diseases. Owing to the position of the interventricular septum (IVS) in the heart, its movement not only relies on contractile properties but is also affected by the pressure gradient between the 2 ventricles and by the mode of electrical activation. Echocardiography allows the operator to focus on the motion of the IVS, analyzing its characteristics and thereby gaining information about the possible underlying pathophysiological mechanism. In this review, we focused on the main echocardiographic patterns of ASM that are not related to a failure of contractile properties of the septum (i.e., acute coronary syndrome and cardiomyopathies), showing their pathophysiological mechanisms and underlining their diagnostic usefulness in clinical practice.
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Affiliation(s)
- Roberta Manganaro
- Department of Clinical and Experimental Medicine, Section of Cardiology, University of Messina, Azienda Ospedaliera Universitaria "Policlinico G. Martino" and Universita' degli Studi di Messina, Messina, Italy
| | - Maurizio Cusmà-Piccione
- Department of Clinical and Experimental Medicine, Section of Cardiology, University of Messina, Azienda Ospedaliera Universitaria "Policlinico G. Martino" and Universita' degli Studi di Messina, Messina, Italy
| | - Scipione Carerj
- Department of Clinical and Experimental Medicine, Section of Cardiology, University of Messina, Azienda Ospedaliera Universitaria "Policlinico G. Martino" and Universita' degli Studi di Messina, Messina, Italy
| | - Roberto Licordari
- Department of Clinical and Experimental Medicine, Section of Cardiology, University of Messina, Azienda Ospedaliera Universitaria "Policlinico G. Martino" and Universita' degli Studi di Messina, Messina, Italy
| | - Bijoy K Khandheria
- Aurora Cardiovascular and Thoracic Services, Aurora Sinai/Aurora St. Luke's Medical Centers, University of Wisconsin School of Medicine and Public Health, Marcus Family Fund for Echocardiography (ECHO) Research and Education, Milwaukee, Wisconsin
| | - Concetta Zito
- Department of Clinical and Experimental Medicine, Section of Cardiology, University of Messina, Azienda Ospedaliera Universitaria "Policlinico G. Martino" and Universita' degli Studi di Messina, Messina, Italy.
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20
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Sun Z, Wang Y, Hu Y, Wu F, Zhang N, Liu Z, Lu J, Li K. Left ventricular dyssynchrony measured by cardiovascular magnetic resonance-feature tracking in anterior ST-elevation myocardial infarction: relationship with microvascular occlusion myocardial damage. Front Cardiovasc Med 2023; 10:1255063. [PMID: 37900576 PMCID: PMC10602888 DOI: 10.3389/fcvm.2023.1255063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2023] [Accepted: 09/25/2023] [Indexed: 10/31/2023] Open
Abstract
Objectives Cardiovascular magnetic resonance-feature tracking (CMR-FT) enables quantification of myocardial deformation and may be used as an objective measure of myocardial involvement in ST-elevation myocardial infarction (STEMI). We sought to investigate the associations between myocardial dyssynchrony parameters and myocardium damage for STEMI. Methods We analyzed 65 patients (45-80 years old) with anterior STEMI after primary percutaneous coronary intervention during 3-7 days [observational (STEMI) group] and 60 healthy volunteers [normal control (NC) group]. Myocardial dyssynchrony parameters were derived, including global and regional strain, radial rebound stretch and displacement, systolic septal time delay, and circumferential stretch. Results CMR characteristics, including morphologic parameters such as left ventricular ejection fraction (LVEF) (45.3% ± 8.2%) and myocardium damage in late gadolinium enhancement (LGE) (19.4% ± 4.7% LV), were assessed in the observation group. The global radial strain (GRS) and global longitudinal strain (GLS) substantially decreased in anterior STEMI compared with the NC group (GRS: 19.4% ± 5.1% vs. 24.8% ± 4.0%, P < 0.05; GLS: -10.1% ± 1.7% vs. -13.7% ± 1.0%, P < 0.05). Among 362 infarcted segments, radial and circumferential peak strains of the infarcted zone were the lowest (14.4% ± 3.2% and -10.7% ± 1.6%, respectively). The radial peak displacement of the infarct zone significantly decreased (2.6 ± 0.4 mm) (P < 0.001) and manifested in the circumferential displacement (3.5° ± 0.7°) in the STEMI group (P < 0.01). As microvascular occlusion (MVO) was additionally present, some strain parameters were significantly impaired in LGE+/MVO+ segments (radial strain [RS]: 12.2% ± 2.1%, circumferential strain [CS]: -9.6% ± 0.7%, longitudinal strain [LS]: -6.8% ± 1.0%) compared to LGE+/MVO- (RS: 14.6% ± 3.2%, CS: -10.8% ± 1.8%, LS: -9.2% ± 1.3%) (P < 0.05). When the extent of transmural myocardial infarction is greater than 75%, the parameter of the systolic septal delay (mean, 148 ms) was significantly reduced compared to fewer degrees of infarction (P < 0.01). Conclusion In anterior STEMI, the infarcted septum swings in a bimodal mode, and myocardial injury reduces the radial strain contractility. A more than 75% transmural degree was the septal strain-contraction reserve cut-off point.
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Affiliation(s)
- Zheng Sun
- Department of Radiology and Nuclear Medicine, Xuanwu Hospital, Capital Medical University, Beijing, China
- Beijing Key Laboratory of Magnetic Resonance Imaging and Brain Informatics, Beijing, China
| | - Yu Wang
- School of Biomedical Engineering, Capital Medical University, Beijing, China
| | - Yingying Hu
- Department of Radiology, The Peking University International Hospital, Beijing, China
| | - Fang Wu
- Department of Radiology and Nuclear Medicine, Xuanwu Hospital, Capital Medical University, Beijing, China
- Beijing Key Laboratory of Magnetic Resonance Imaging and Brain Informatics, Beijing, China
| | - Nan Zhang
- School of Biomedical Engineering, Capital Medical University, Beijing, China
| | - Zhi Liu
- Department of Emergency, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Jie Lu
- Department of Radiology and Nuclear Medicine, Xuanwu Hospital, Capital Medical University, Beijing, China
- Beijing Key Laboratory of Magnetic Resonance Imaging and Brain Informatics, Beijing, China
| | - Kuncheng Li
- Department of Radiology and Nuclear Medicine, Xuanwu Hospital, Capital Medical University, Beijing, China
- Beijing Key Laboratory of Magnetic Resonance Imaging and Brain Informatics, Beijing, China
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21
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Kader N, Holm-Nielsen LT, Tayal B, Riahi S, Sommer A, Nielsen JC, Kronborg MB, Stephansen C, Andersen NH, Risum N, Søgaard P, Zaremba T. Contractile asymmetry and survival in patients with left bundle branch abnormality treated with cardiac resynchronization therapy. EUROPEAN HEART JOURNAL. IMAGING METHODS AND PRACTICE 2023; 1:qyad045. [PMID: 39045065 PMCID: PMC11195769 DOI: 10.1093/ehjimp/qyad045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 12/13/2023] [Indexed: 07/25/2024]
Abstract
Aims Currently, electrical rather than mechanical parameters of delayed left ventricular (LV) activation are used for patient selection for cardiac resynchronization therapy (CRT). However, despite adhering to current guideline-based criteria, about one-third of heart failure (HF) patients fail to derive benefit from CRT. This study sought to investigate the prognostic survival significance of a recently introduced index of contractile asymmetry (ICA) based on the deformation of entire opposing LV walls in the context of selecting patients with HF and left bundle branch abnormality (LBBB) for CRT. Methods and results We analysed 367 patients with HF and LBBB undergoing CRT (31.6% females, 69 ± 9 years, ischaemic aetiology in 50.7%, LV ejection fraction 27 ± 6%). ICA was calculated using LV strain rate values from curved anatomical M-mode plots of apical 2D echocardiography images. The predictive value of ICA was assessed using Kaplan-Meier analysis and Cox proportional hazards models. During a median follow-up time of 5.54 years, death or cardiac transplantation occurred in 105 (28.6%) cases. Higher baseline ICA values in all apical views, particularly in the two-chamber view (ICA-2ch), were associated with increased event-free survival, and the unadjusted hazard ratio was 0.28 (95% confidence interval 0.18-0.46). Higher ICA-2ch (>0.319 s-1) consistently predicted survival across clinical subgroups and remained significant after covariate adjustment, while the event rate sharply increased in low ICA-2ch cases. Additionally, including ICA-2ch improved the predictive value of the multivariate risk model containing the typical LBBB pattern. Conclusion Pre-implant ICA suggests a quantitative prognostic threshold for both long-term survival and adverse outcomes following CRT implantation.
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Affiliation(s)
- Nareen Kader
- Department of Cardiology, Aalborg University Hospital, Hobrovej 18-22, 9100 Aalborg, Denmark
| | | | - Bhupendar Tayal
- Department of Cardiology, Aalborg University Hospital, Hobrovej 18-22, 9100 Aalborg, Denmark
| | - Sam Riahi
- Department of Cardiology, Aalborg University Hospital, Hobrovej 18-22, 9100 Aalborg, Denmark
| | - Anders Sommer
- Department of Cardiology, Aalborg University Hospital, Hobrovej 18-22, 9100 Aalborg, Denmark
| | - Jens Cosedis Nielsen
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | | | | | - Niels Holmark Andersen
- Department of Cardiology, Aalborg University Hospital, Hobrovej 18-22, 9100 Aalborg, Denmark
| | - Niels Risum
- Department of Cardiology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Peter Søgaard
- Department of Cardiology, Aalborg University Hospital, Hobrovej 18-22, 9100 Aalborg, Denmark
| | - Tomas Zaremba
- Department of Cardiology, Aalborg University Hospital, Hobrovej 18-22, 9100 Aalborg, Denmark
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22
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Brandt RR, Stöbe S, Ewers A, Helfen A. [Echocardiography in cardiac arrhythmias]. Herzschrittmacherther Elektrophysiol 2023; 34:256-264. [PMID: 37584761 DOI: 10.1007/s00399-023-00956-1] [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: 07/03/2023] [Accepted: 07/19/2023] [Indexed: 08/17/2023]
Abstract
Echocardiography plays a key role in planning and guidance of electrophysiological procedures. After exclusion of structural heart disease, echocardiography provides insight into the extent of left atrial remodeling by determining left atrial metrics. This "biomarker" is associated with the risk of new-onset atrial fibrillation and predictive of atrial fibrillation recurrence after ablation. Transesophageal echocardiography is necessary to exclude left atrial thrombi and is able to guide a transseptal puncture. In case of a rare but life-threatening cardiac tamponade, an echocardiographic-guided pericardiocentesis ensures quick and effective treatment. Left ventricular ejection fraction and deformation analysis determined by echocardiography are established methods for risk stratification in patients with systolic dysfunction and used to guide pharmacological and device therapy.
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Affiliation(s)
- Roland R Brandt
- Abteilung für Kardiologie, Kerckhoff Klinik GmbH, Benekestr. 2-8, 61231, Bad Nauheim, Deutschland.
| | - Stephan Stöbe
- Klinik und Poliklinik für Kardiologie, Universitätsklinikum Leipzig, Liebigstr. 20, 04103, Leipzig, Deutschland
| | - Aydan Ewers
- Medizinische Universitätsklinik II - Kardiologie und Angiologie, BG Universitätsklinikum Bergmannsheil Bochum, Bürkle de la Camp-Platz 1, 44789, Bochum, Deutschland
| | - Andreas Helfen
- Abteilung für Kardiologie, Katholische St. Paulus Gesellschaft, St.-Marien-Hospital Lünen, Altstadtstr. 23, 44534, Lünen, Deutschland
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23
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Pujol-López M, Tolosana JM, Upadhyay GA, Mont L, Tung R. Left Bundle Branch Block: Characterization, Definitions, and Recent Insights into Conduction System Physiology. Cardiol Clin 2023; 41:379-391. [PMID: 37321688 DOI: 10.1016/j.ccl.2023.03.003] [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] [Indexed: 06/17/2023]
Abstract
Left bundle branch block (LBBB) is not just a simple electrocardiogram alteration. The intricacies of this general terminology go beyond simple conduction block. This review puts together current knowledge on the historical concept of LBBB, clinical significance, and recent insights into the pathophysiology of human LBBB. LBBB is an entity that affects patient diagnosis (primary conduction disease, secondary to underlying pathology or iatrogenic), treatment (cardiac resynchronization therapy or conduction system pacing for heart failure), and prognosis. Recruiting the left bundle branch with conduction system pacing depends on the complex interaction between anatomy, site of pathophysiology, and delivery tools.
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Affiliation(s)
- Margarida Pujol-López
- Arrhythmia Section, Cardiology Department, Institut Clínic Cardiovascular, Hospital Clínic de Barcelona, Universitat de Barcelona, C/ Villarroel 170, Barcelona, Catalonia 08036, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Catalonia, Spain
| | - José M Tolosana
- Arrhythmia Section, Cardiology Department, Institut Clínic Cardiovascular, Hospital Clínic de Barcelona, Universitat de Barcelona, C/ Villarroel 170, Barcelona, Catalonia 08036, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Catalonia, Spain; Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares, Madrid, Spain
| | - Gaurav A Upadhyay
- Center for Arrhythmia Care, Pritzker School of Medicine, University of Chicago, The University of Chicago Medicine, Heart and Vascular Center, 5841 South Maryland Avenue, Chicago, IL 60637, USA
| | - Lluís Mont
- Arrhythmia Section, Cardiology Department, Institut Clínic Cardiovascular, Hospital Clínic de Barcelona, Universitat de Barcelona, C/ Villarroel 170, Barcelona, Catalonia 08036, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Catalonia, Spain; Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares, Madrid, Spain
| | - Roderick Tung
- Center for Arrhythmia Care, Pritzker School of Medicine, University of Chicago, The University of Chicago Medicine, Heart and Vascular Center, 5841 South Maryland Avenue, Chicago, IL 60637, USA.
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Ye Y, Lv Y, Mao Y, Li L, Chen X, Zheng R, Hou X, Yu C, Gabriella C, Fu GS. Cardiovascular imaging in conduction system pacing: What does the clinician need? Pacing Clin Electrophysiol 2023; 46:548-557. [PMID: 36516139 DOI: 10.1111/pace.14644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 12/03/2022] [Accepted: 12/07/2022] [Indexed: 12/15/2022]
Abstract
Permanent pacemakers are used for symptomatic bradycardia and biventricular pacing (BVP)-cardiac resynchronization therapy (BVP-CRT) is established for heart failure (HF) patients traditionally. According to guidelines, patients' selection for CRT is based on QRS duration (QRSd) and morphology by surface electrocardiogram (ECG). Cardiovascular imaging techniques evaluate cardiac structure and function as well as identify pathophysiological substrate changes including the presence of scar. Cardiovascular imaging helps by improving the selection of candidates, guiding left ventricular (LV) lead placement, and optimization devices during the follow-up. Conduction system pacing (CSP) includes His bundle pacing (HBP) and left bundle branch pacing (LBBP) which is screwed into the interventricular septum. CSP maintains and restores ventricular synchrony in patients with native narrow QRSd and left bundle branch block (LBBB), respectively. LBBP is more feasible than HBP due to a wider target area. This review highlights the role of multimodality cardiovascular imaging including fluoroscopy, echocardiography, cardiac magnetic resonance (CMR), myocardial scintigraphy, and computed tomography (CT) in the pre-procedure assessment for CSP, better selection for CSP candidates, the guidance of CSP lead implantation, and the optimization of devices programming after the procedure. We also compare the different characteristics of multimodality imaging and discuss their potential roles in future CSP implantation.
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Affiliation(s)
- Yang Ye
- Department of Cardiology, Key Laboratory of Cardiovascular Intervention and Regenerative Medicine of Zhejiang Province, Sir Run Run Shaw Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, People's Republic of China
| | - Yuan Lv
- Department of Cardiology, Key Laboratory of Cardiovascular Intervention and Regenerative Medicine of Zhejiang Province, Sir Run Run Shaw Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, People's Republic of China
| | - Yankai Mao
- Department of Diagnostic Ultrasound and Echocardiology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China
| | - Lin Li
- Department of Radiology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China
| | - Xueying Chen
- Shanghai Institution of Cardiovascular Disease, Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Rujie Zheng
- Department of Cardiology, The First Affiliated Hospital of Wenzhou Medical University, Key Lab of Cardiovascular Disease of Wenzhou, Wenzhou, China
| | - Xiaofeng Hou
- Department of Cardiology, First Affiliated Hospital, Nanjing Medical University, Nanjing, Jiangsu, China
| | - Chan Yu
- Department of Diagnostic Ultrasound and Echocardiology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China
| | - Captur Gabriella
- Institute of Cardiovascular Science, University College London, London, UK
- Centre for Inherited Heart Muscle Conditions, Department of Cardiology, Royal Free London NHS Foundation Trust, London, UK
- Medical Research Council Unit for Lifelong Health and Ageing at UCL, London, UK
| | - Guo-Sheng Fu
- Department of Cardiology, Key Laboratory of Cardiovascular Intervention and Regenerative Medicine of Zhejiang Province, Sir Run Run Shaw Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, People's Republic of China
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Yuan Y, Sun J, Jin D, Zhao S. Quantitative left ventricular mechanical dyssynchrony by magnetic resonance imaging predicts the prognosis of dilated cardiomyopathy. Eur J Radiol 2023; 164:110847. [PMID: 37182417 DOI: 10.1016/j.ejrad.2023.110847] [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: 01/07/2023] [Revised: 04/15/2023] [Accepted: 04/21/2023] [Indexed: 05/16/2023]
Abstract
PURPOSE Left ventricular (LV) dyssynchrony is believed to be associated with the prognosis of dilated cardiomyopathy (DCM) mainly assessed by echocardiography. This study sought to explore whether quantitative LV mechanical dyssynchrony by cardiovascular magnetic resonance imaging (CMR) tissue feature tracking could predict the prognosis of DCM. METHOD Patients undergoing CMR between January 2016 and December 2017 were reviewed to identify DCM patients. Quantitative LV mechanical dyssynchrony was assessed by CMR strain analysis. The outcomes of these DCM patients were followed up. The association between LV mechanical dyssynchrony and outcomes was analyzed by Cox proportional regression analysis. RESULTS A total of 417 patients with DCM were enrolled. At a median follow-up of 57 months, 109 patients reached endpoints: 19, sudden cardiac death; 34, heart failure death; 41, heart transplantation; 9, malignant ventricular arrhythmias; 2, LV assist devices; and 4, appropriate shocks of defibrillators. After adjustment for confounding variables, the 16-segment standard deviation of the time-to-peak radial strain (16SDTTPRS) (HR, 1.932 [95% CI: 1.079, 3.461]; P = 0.027), LV end-diastolic diameter index (HR, 1.049 [95% CI: 1.020, 1.080]; P = 0.001), NYHA classes (HR, 2.131 [95% CI: 1.597-2.844]; P < 0.001) and late gadolinium enhancement (HR, 3.219 [95% CI: 2.164, 4.787]; P < 0.001) were independently associated with composite endpoints. CONCLUSIONS The quantitative LV mechanical dyssynchrony parameter 16SDTTPRS derived from CMR was independently associated with adverse outcomes in patients with DCM.
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Affiliation(s)
- Yong Yuan
- Department of Magnetic Resonance Imaging, Cardiovascular Imaging and Intervention Center, Fuwai Hospital, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China; Department of Diagnostic Imaging, Geriatric Hospital of Nanjing Medical University, Nanjing 210024, China
| | - Jinghua Sun
- Department of Medical Imaging, Tangshan Worker's Hospital, Tangshan, Hebei 063000, China
| | - Dongsheng Jin
- Department of Diagnostic Imaging, Geriatric Hospital of Nanjing Medical University, Nanjing 210024, China.
| | - Shihua Zhao
- Department of Magnetic Resonance Imaging, Cardiovascular Imaging and Intervention Center, Fuwai Hospital, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China.
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26
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Galli E, Galand V, Le Rolle V, Taconne M, Wazzan AA, Hernandez A, Leclercq C, Donal E. The saga of dyssynchrony imaging: Are we getting to the point. Front Cardiovasc Med 2023; 10:1111538. [PMID: 37063957 PMCID: PMC10103462 DOI: 10.3389/fcvm.2023.1111538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 02/27/2023] [Indexed: 04/03/2023] Open
Abstract
Cardiac resynchronisation therapy (CRT) has an established role in the management of patients with heart failure, reduced left ventricular ejection fraction (LVEF < 35%) and widened QRS (>130 msec). Despite the complex pathophysiology of left ventricular (LV) dyssynchrony and the increasing evidence supporting the identification of specific electromechanical substrates that are associated with a higher probability of CRT response, the assessment of LVEF is the only imaging-derived parameter used for the selection of CRT candidates.This review aims to (1) provide an overview of the evolution of cardiac imaging for the assessment of LV dyssynchrony and its role in the selection of patients undergoing CRT; (2) highlight the main pitfalls and advantages of the application of cardiac imaging for the assessment of LV dyssynchrony; (3) provide some perspectives for clinical application and future research in this field.Conclusionthe road for a more individualized approach to resynchronization therapy delivery is open and imaging might provide important input beyond the assessment of LVEF.
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27
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Radu AD, Cojocaru C, Onciul S, Scarlatescu A, Zlibut A, Nastasa A, Dorobantu M. Cardiac Resynchronization Therapy and Hypertrophic Cardiomyopathy: A Comprehensive Review. Biomedicines 2023; 11:350. [PMID: 36830887 PMCID: PMC9952999 DOI: 10.3390/biomedicines11020350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Revised: 01/21/2023] [Accepted: 01/24/2023] [Indexed: 01/28/2023] Open
Abstract
Hypertrophic cardiomyopathy (HCM) is an inherited primary myocardial disease characterized by asymmetrical/symmetrical left ventricle (LV) hypertrophy, with or without LV outflow tract (LVOT) dynamic obstruction, and poor prognosis. Cardiac resynchronization therapy (CRT) has emerged as a minimally invasive tool for patients with heart failure (HF) with decreased LV ejection fraction (LVEF) and prolonged QRS duration of over 120 ms with or without left bundle branch block (LBBB). Several HCM patients are at risk of developing LBBB because of disease progression or secondary to septal myomectomy, while others might develop HF with decreased LVEF, alleged end-stage/dilated HCM, especially those with thin myofilament mutations. Several studies have shown that patients with myectomy-induced LBBB might benefit from left bundle branch pacing or CRT to relieve symptoms, improve exercise capacity, and increase LVEF. Otherwise, patients with end-stage/dilated HCM and prolonged QRS interval could gain from CRT in terms of NYHA class improvement, LV systolic performance increase and, to some degree, LV reverse remodeling. Moreover, several electrical and imaging parameters might aid proper selection and stratification of HCM patients to benefit from CRT. Nonetheless, current available data are scarce and further studies are still required to accurately clarify the view. This review reassesses the importance of CRT in patients with HCM based on current research by contrasting and contextualizing data from various published studies.
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Affiliation(s)
- Andrei Dan Radu
- Cardiology Department, Emergency Clinical Hospital of Bucharest, 014461 Bucharest, Romania
- Faculty of Medicine, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | - Cosmin Cojocaru
- Cardiology Department, Emergency Clinical Hospital of Bucharest, 014461 Bucharest, Romania
- Faculty of Medicine, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | - Sebastian Onciul
- Cardiology Department, Emergency Clinical Hospital of Bucharest, 014461 Bucharest, Romania
- Faculty of Medicine, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | - Alina Scarlatescu
- Cardiology Department, Emergency Clinical Hospital of Bucharest, 014461 Bucharest, Romania
| | - Alexandru Zlibut
- Cardiology Department, Emergency Clinical Hospital of Bucharest, 014461 Bucharest, Romania
- Department of Internal Medicine, Iuliu Hatieganu University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania
| | - Alexandrina Nastasa
- Cardiology Department, “Elias” University Emergency Hospital, 011461 Bucharest, Romania
| | - Maria Dorobantu
- Cardiology Department, Emergency Clinical Hospital of Bucharest, 014461 Bucharest, Romania
- Faculty of Medicine, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
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28
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Galli E, Baritussio A, Sitges M, Donnellan E, Jaber WA, Gimelli A. Multi-modality imaging to guide the implantation of cardiac electronic devices in heart failure: is the sum greater than the individual components? Eur Heart J Cardiovasc Imaging 2023; 24:163-176. [PMID: 36458875 DOI: 10.1093/ehjci/jeac237] [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: 07/22/2022] [Accepted: 11/03/2022] [Indexed: 12/05/2022] Open
Abstract
Heart failure is a clinical syndrome with an increasing prevalence and incidence worldwide that impacts patients' quality of life, morbidity, and mortality. Implantable cardioverter-defibrillator and cardiac resynchronization therapy are pillars of managing patients with HF and reduced left ventricular ejection fraction. Despite the advances in cardiac imaging, the assessment of patients needing cardiac implantable electronic devices relies essentially on the measure of left ventricular ejection fraction. However, multi-modality imaging can provide important information concerning the aetiology of heart failure, the extent and localization of myocardial scar, and the pathophysiological mechanisms of left ventricular conduction delay. This paper aims to highlight the main novelties and progress in the field of multi-modality imaging to identify patients who will benefit from cardiac resynchronization therapy and/or implantable cardioverter-defibrillator. We also want to underscore the boundaries that prevent the application of imaging-derived parameters to patients who will benefit from cardiac implantable electronic devices and orient the choice of the device. Finally, we aim at providing some reflections for future research in this field.
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Affiliation(s)
- Elena Galli
- Department of Cardiology, University Hospital of Rennes, 35000 Rue Henri Le Guilloux, Rennes, France
| | - Anna Baritussio
- Cardiology, Department of Cardiac, Vascular, Thoracic Sciences and Public Health, University Hospital of Padua, 35121 Via Nicolò Giustiniani, Padua, Italy
| | - Marta Sitges
- Cardiovascular Institute, Hospital Clínic, Universitat de Barcelona, 08036 C. de Villarroel, Barcelona, Spain
| | - Eoin Donnellan
- Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Wael A Jaber
- Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Alessia Gimelli
- Fondazione Toscana G. Monasterio, 56124 Via Giuseppe Moruzzi, Pisa, Italy
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29
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Finding New Insights in Cardiac Resynchronization Therapy and the Pathophysiology behind Left Ventricular Dyssynchrony. J Clin Med 2022; 11:jcm11226831. [PMID: 36431306 PMCID: PMC9697980 DOI: 10.3390/jcm11226831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Accepted: 11/16/2022] [Indexed: 11/22/2022] Open
Abstract
Over the past two decades, cardiac resynchronization therapy (CRT) became an established treatment option for patients with symptomatic heart failure [...].
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30
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Soman P, Malhotra S. Left Bundle Branch Block and Cardiac Resynchronization Therapy: Effector or Bystander? Circ Cardiovasc Imaging 2022; 15:e014849. [PMID: 36330794 DOI: 10.1161/circimaging.122.014849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Prem Soman
- Division of Cardiology, University of Pittsburgh Medical Center, PA (P.S.)
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31
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Calle S, Duchenne J, Beela AS, Stankovic I, Puvrez A, Winter S, Fehske W, Aarones M, De Buyzere M, De Pooter J, Voigt JU, Timmermans F. Clinical and Experimental Evidence for a Strain-Based Classification of Left Bundle Branch Block-Induced Cardiac Remodeling. Circ Cardiovasc Imaging 2022; 15:e014296. [PMID: 36330792 DOI: 10.1161/circimaging.122.014296] [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] [Indexed: 11/06/2022]
Abstract
BACKGROUND Septal strain patterns measured by echocardiography reflect the severity of left bundle branch block (LBBB)-induced left ventricular (LV) dysfunction. We investigated whether these LBBB strain stages predicted the response to cardiac resynchronization therapy in an observational study and developed a sheep model of LBBB-induced cardiomyopathy. METHODS The clinical study enrolled cardiac resynchronization therapy patients who underwent echocardiographic examination with speckle-tracking strain analysis before cardiac resynchronization therapy implant. In an experimental sheep model with pacing-induced dyssynchrony, LV remodeling and strain were assessed at baseline, at 8 and 16 weeks. Septal strain curves were classified into 5 patterns (LBBB-0 to LBBB-4). RESULTS The clinical study involved 250 patients (age 65 [58; 72] years; 79% men; 89% LBBB) with a median LV ejection fraction of 25 [21; 30]%. Across the stages, cardiac resynchronization therapy resulted in a gradual volumetric response, ranging from no response in LBBB-0 patients (ΔLV end-systolic volume 0 [-12; 15]%) to super-response in LBBB-4 patients (ΔLV end-systolic volume -44 [-64; -18]%) (P<0.001). LBBB-0 patients had a less favorable long-term outcome compared with those in stage LBBB≥1 (log-rank P=0.003). In 13 sheep, acute right ventricular pacing resulted in LBBB-1 (23%) and LBBB-2 (77%) patterns. Over the course of 8-16 weeks, continued pacing resulted in progressive LBBB-induced dysfunction, coincident with a transition to advanced strain patterns (92% LBBB-2 and 8% LBBB-3 at week 8; 75% LBBB-3 and 25% LBBB-4 at week 16) (P=0.023). CONCLUSIONS The strain-based LBBB classification reflects a pathophysiological continuum of LBBB-induced remodeling over time and is associated with the extent of reverse remodeling in observational cardiac resynchronization therapy-eligible patients.
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Affiliation(s)
- Simon Calle
- Department of Cardiology, University Hospital Ghent, Belgium (S.C., M.D.B., J.D.P., F.T.)
| | - Jürgen Duchenne
- Department of Cardiovascular Sciences, KU Leuven, Belgium (J.D., A.S.B., I.S., A.P., J.-U.V.).,Department of Cardiovascular Diseases, University Hospital Leuven, Belgium (J.D., A.P., J.-U.V.)
| | - Ahmed S Beela
- Department of Cardiovascular Sciences, KU Leuven, Belgium (J.D., A.S.B., I.S., A.P., J.-U.V.).,Department of Biomedical Engineering, Cardiovascular Research Institute Maastricht, the Netherlands (A.S.B.).,Department of Cardiovascular Diseases, Suez Canal University, Egypt (A.S.B.)
| | - Ivan Stankovic
- Department of Cardiovascular Sciences, KU Leuven, Belgium (J.D., A.S.B., I.S., A.P., J.-U.V.).,Clinical Hospital Centre Zemun, Faculty of Medicine, University of Belgrade, Serbia (I.S.)
| | - Alexis Puvrez
- Department of Cardiovascular Sciences, KU Leuven, Belgium (J.D., A.S.B., I.S., A.P., J.-U.V.).,Department of Cardiovascular Diseases, University Hospital Leuven, Belgium (J.D., A.P., J.-U.V.)
| | - Stefan Winter
- Department of Cardiology, St. Vinzenz Hospital, Germany (S.W., W.F.)
| | - Wolfgang Fehske
- Department of Cardiology, St. Vinzenz Hospital, Germany (S.W., W.F.)
| | - Marit Aarones
- Department of Medicine, Diakonhjemmet Hospital, Norway (M.A.H.)
| | - Marc De Buyzere
- Department of Cardiology, University Hospital Ghent, Belgium (S.C., M.D.B., J.D.P., F.T.)
| | - Jan De Pooter
- Department of Cardiology, University Hospital Ghent, Belgium (S.C., M.D.B., J.D.P., F.T.)
| | - Jens-Uwe Voigt
- Department of Cardiovascular Sciences, KU Leuven, Belgium (J.D., A.S.B., I.S., A.P., J.-U.V.).,Department of Cardiovascular Diseases, University Hospital Leuven, Belgium (J.D., A.P., J.-U.V.)
| | - Frank Timmermans
- Department of Cardiology, University Hospital Ghent, Belgium (S.C., M.D.B., J.D.P., F.T.)
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32
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Trifunović-Zamaklar D, Jovanović I, Vratonjić J, Petrović O, Paunović I, Tešić M, Boričić-Kostić M, Ivanović B. The basic heart anatomy and physiology from the cardiologist's perspective: Toward a better understanding of left ventricular mechanics, systolic, and diastolic function. JOURNAL OF CLINICAL ULTRASOUND : JCU 2022; 50:1026-1040. [PMID: 36218206 DOI: 10.1002/jcu.23316] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Revised: 08/23/2022] [Accepted: 08/24/2022] [Indexed: 06/16/2023]
Abstract
A comprehensive understanding of the cardiac structure-function relationship is essential for proper clinical cardiac imaging. This review summarizes the basic heart anatomy and physiology from the perspective of a heart imager focused on myocardial mechanics. The main issues analyzed are the left ventricular (LV) architecture, the LV myocardial deformation through the cardiac cycle, the LV diastolic function basic parameters and the basic parameters of the LV deformation used in clinical practice for the LV function assessment.
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Affiliation(s)
- Danijela Trifunović-Zamaklar
- Clinic for Cardiology, University Clinical Center of Serbia, Belgrade, Serbia
- School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Ivana Jovanović
- Clinic for Cardiology, University Clinical Center of Serbia, Belgrade, Serbia
| | - Jelena Vratonjić
- Clinic for Cardiology, University Clinical Center of Serbia, Belgrade, Serbia
| | - Olga Petrović
- Clinic for Cardiology, University Clinical Center of Serbia, Belgrade, Serbia
- School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Ivana Paunović
- Clinic for Cardiology, University Clinical Center of Serbia, Belgrade, Serbia
| | - Milorad Tešić
- Clinic for Cardiology, University Clinical Center of Serbia, Belgrade, Serbia
- School of Medicine, University of Belgrade, Belgrade, Serbia
| | | | - Branislava Ivanović
- Clinic for Cardiology, University Clinical Center of Serbia, Belgrade, Serbia
- School of Medicine, University of Belgrade, Belgrade, Serbia
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33
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Wang S, Lyu Y, Cheng S, Zhang Y, Gu X, Gong M, Liu J. Smaller left ventricular end-systolic diameter and lower ejection fraction at baseline associated with greater ejection fraction improvement after revascularization among patients with left ventricular dysfunction. Front Cardiovasc Med 2022; 9:967039. [PMID: 36247459 PMCID: PMC9559822 DOI: 10.3389/fcvm.2022.967039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2022] [Accepted: 09/13/2022] [Indexed: 11/25/2022] Open
Abstract
Objectives To investigate the predictive roles of pre-operative left ventricular (LV) size and ejection fraction (EF) in EF improvement and outcome following revascularization in patients with coronary artery disease (CAD) and LV dysfunction. Background Revascularization may improve EF and long-term outcomes of patients with LV dysfunction. However, the determinants of EF improvement have not yet been investigated comprehensively. Materials and methods Patients with EF measurements before and 3 months after revascularization were enrolled in a cohort study (No. ChiCTR2100044378). All patients had baseline EF ≤ 40%. EF improvement was defined as absolute increase in EF > 5%. According to LV end-systolic diameter (LVESD) (severely enlarged or not) and EF (≤35% or of 36–40%) at baseline, patients were categorized into four groups. Results A total of 939 patients were identified. A total of 549 (58.5%) had EF improved. Both LVESD [odds ratio (OR) per 1 mm decrease, 1.05; 95% CI, 1.04–1.07; P < 0.001] and EF (OR per 1% decrease, 1.06; 95% CI, 1.03–1.10; P < 0.001) at baseline were predictive of EF improvement after revascularization. Patients with LVESD not severely enlarged and EF ≤ 35% had higher odds of being in the EF improved group in comparison with other three groups both in unadjusted and adjusted analysis (all P < 0.001). The median follow-up time was 3.5 years. Patients with LVESD not severely enlarged and EF ≤ 35% had significantly lower risk of all-cause death in comparison with patients with LVESD severely enlarged and EF ≤ 35% [hazard ratio (HR), 2.73; 95% CI, 1.28–5.82; P = 0.009], and tended to have lower risk in comparison with patients with LVESD severely enlarged and EF of 36–40% (HR, 2.00; 95% CI, 0.93–4.27; P = 0.074). Conclusion Among CAD patients with reduced EF (≤ 40%) who underwent revascularization, smaller pre-operative LVESD and lower EF had greatest potential to have EF improvement and better outcome. Our findings imply the indication for revascularization in patients with LV dysfunction who presented with lower EF but smaller LV size.
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Affiliation(s)
- Shaoping Wang
- Department of Cardiology, Beijing Anzhen Hospital, Beijing Institute of Heart Lung and Blood Vessel Diseases, Capital Medical University, Beijing, China
| | - Yi Lyu
- Department of Anesthesiology, Minhang Hospital, Fudan University, Shanghai, China
| | - Shujuan Cheng
- Department of Cardiology, Beijing Anzhen Hospital, Beijing Institute of Heart Lung and Blood Vessel Diseases, Capital Medical University, Beijing, China
| | - Yuchao Zhang
- Department of Cardiology, Beijing Anzhen Hospital, Beijing Institute of Heart Lung and Blood Vessel Diseases, Capital Medical University, Beijing, China
| | - Xiaoyan Gu
- Department of Echocardiography, Beijing Anzhen Hospital, Beijing Institute of Heart Lung and Blood Vessel Diseases, Capital Medical University, Beijing, China
| | - Ming Gong
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Beijing Institute of Heart Lung and Blood Vessel Diseases, Capital Medical University, Beijing, China
| | - Jinghua Liu
- Department of Cardiology, Beijing Anzhen Hospital, Beijing Institute of Heart Lung and Blood Vessel Diseases, Capital Medical University, Beijing, China
- *Correspondence: Jinghua Liu,
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Kong NW, Upadhyay GA. Cardiac resynchronization considerations in left bundle branch block. Front Physiol 2022; 13:962042. [PMID: 36187776 PMCID: PMC9520457 DOI: 10.3389/fphys.2022.962042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2022] [Accepted: 08/30/2022] [Indexed: 11/18/2022] Open
Abstract
Cardiac resynchronization therapy (CRT) via biventricular pacing (BiVP) is an established treatment for patients with left ventricular systolic heart failure and intraventricular conduction delay resulting in wide QRS. Seminal trials demonstrating mortality benefit from CRT were conducted in patients with wide left bundle branch block (LBBB) pattern on electrocardiogram (ECG) and evidence of clinical heart failure. The presence of conduction block was assumed to correlate with commonly applied criteria for LBBB. More recent data has challenged this assertion, revealing that LBBB pattern may include distinct underlying pathophysiology, including patients with complete conduction block, either at the left-sided His fibers or the proximal left bundle, intact Purkinje activation with wide LBBB-like QRS, and patients demonstrating both proximal block and distal delay. Currently, BiVP-CRT is indicated for all QRS duration ≥150 ms and may be considered for BBB patterns from 130 to 149 ms with robust clinical data to support its use. Despite this, however, there remains a significant number of non-responders to BVP. Conduction system pacing (CSP) has emerged as an alternative approach to deliver CRT and correct QRS in patients with conduction block. Newer hybrid approaches which combine CSP and traditional BiVP-CRT and may hold promise for patients with IP or mixed-level block. As various approaches to CRT continue to be studied, physiologic phenotyping of the LBBB pattern remains an important consideration.
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Affiliation(s)
- Nathan W. Kong
- Department of Internal Medicine, University of Chicago Medicine, Chicago, IL, United States
| | - Gaurav A. Upadhyay
- Section of Cardiology, Center for Arrhythmia Care, University of Chicago Medicine, Chicago, IL, United States
- *Correspondence: Gaurav A. Upadhyay,
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Wang S, Cheng S, Zhang Y, Lyu Y, Liu J. Extent of Ejection Fraction Improvement After Revascularization Associated with Outcomes Among Patients with Ischemic Left Ventricular Dysfunction. Int J Gen Med 2022; 15:7219-7228. [PMID: 36124105 PMCID: PMC9482409 DOI: 10.2147/ijgm.s380276] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 08/29/2022] [Indexed: 11/23/2022] Open
Abstract
Purpose Ejection fraction (EF) has been reported to be a major predictor of improved survival in patients with heart failure. However, it is largely unknown whether the extent of improvement in EF affects the subsequent risk of mortality. This study sought to investigate change in EF after revascularization and the implication of these changes on clinical outcomes among patients with ischemic left ventricular dysfunction. Patients and Methods We conducted a cohort study (No. ChiCTR2100044378) of patients with reduced EF (≤40%) who received revascularization and had EF reassessment by echocardiography 3 months after revascularization. Patients were categorized according to the absolute change in EF: 1) EF worsened group (absolute decrease in EF >5%); 2) EF unchanged group (absolute change in EF −5% to 5%); 3) EF improved group (absolute increase in EF >5%). Results Of 974 patients, 84 (8.6%) had EF worsened, 317 (32.5%) had EF unchanged and 573 (58.8%) had EF improved. The median follow-up time was 3.5 years, during which 143 patients died. For each 5-unit increments in EF, the risk of death decreased by 20% (hazard ratio, HR, per 5% increases, 0.80; 95% CI, 0.73–0.86; P<0.001). Compared with EF improvement group, patients with EF worsened (HR, 3.35; 95% CI, 2.07–5.42; P<0.001) and patients with EF unchanged (HR, 2.05; 95% CI, 1.40–3.01; P<0.001) had significantly higher risk of all-cause death. Conclusion Changes in EF were inversely associated with the risk of mortality. The extent of EF improvement after revascularization might be a potential factor which defines clinical outcomes.
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Affiliation(s)
- Shaoping Wang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing, People’s Republic of China
| | - Shujuan Cheng
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing, People’s Republic of China
| | - Yuchao Zhang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing, People’s Republic of China
| | - Yi Lyu
- Department of Anesthesiology, Minhang Hospital, Fudan University, Shanghai, People’s Republic of China
- Yi Lyu, Department of Anesthesiology, Minhang Hospital, Fudan University, No. 180 Xinsong Road, Minhang District, Shanghai, 201199, People’s Republic of China, Email
| | - Jinghua Liu
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing, People’s Republic of China
- Correspondence: Jinghua Liu, Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, No. 2 Anzhen Road, Chaoyang District, Beijing, 100029, People’s Republic of China, Tel +86 10 64456998, Fax +86 1064456998, Email
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36
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Puyol-Antón E, Sidhu BS, Gould J, Porter B, Elliott MK, Mehta V, Rinaldi CA, King AP. A multimodal deep learning model for cardiac resynchronisation therapy response prediction. Med Image Anal 2022; 79:102465. [PMID: 35487111 PMCID: PMC7616169 DOI: 10.1016/j.media.2022.102465] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 01/03/2022] [Accepted: 04/15/2022] [Indexed: 01/03/2023]
Abstract
We present a novel multimodal deep learning framework for cardiac resynchronisation therapy (CRT) response prediction from 2D echocardiography and cardiac magnetic resonance (CMR) data. The proposed method first uses the 'nnU-Net' segmentation model to extract segmentations of the heart over the full cardiac cycle from the two modalities. Next, a multimodal deep learning classifier is used for CRT response prediction, which combines the latent spaces of the segmentation models of the two modalities. At test time, this framework can be used with 2D echocardiography data only, whilst taking advantage of the implicit relationship between CMR and echocardiography features learnt from the model. We evaluate our pipeline on a cohort of 50 CRT patients for whom paired echocardiography/CMR data were available, and results show that the proposed multimodal classifier results in a statistically significant improvement in accuracy compared to the baseline approach that uses only 2D echocardiography data. The combination of multimodal data enables CRT response to be predicted with 77.38% accuracy (83.33% sensitivity and 71.43% specificity), which is comparable with the current state-of-the-art in machine learning-based CRT response prediction. Our work represents the first multimodal deep learning approach for CRT response prediction.
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Affiliation(s)
- Esther Puyol-Antón
- School of Biomedical Engineering & Imaging Sciences, King's College London, UK.
| | - Baldeep S Sidhu
- School of Biomedical Engineering & Imaging Sciences, King's College London, UK; Guy's and St Thomas' Hospital, London, UK
| | - Justin Gould
- School of Biomedical Engineering & Imaging Sciences, King's College London, UK; Guy's and St Thomas' Hospital, London, UK
| | - Bradley Porter
- School of Biomedical Engineering & Imaging Sciences, King's College London, UK; Guy's and St Thomas' Hospital, London, UK
| | - Mark K Elliott
- School of Biomedical Engineering & Imaging Sciences, King's College London, UK; Guy's and St Thomas' Hospital, London, UK
| | - Vishal Mehta
- School of Biomedical Engineering & Imaging Sciences, King's College London, UK; Guy's and St Thomas' Hospital, London, UK
| | - Christopher A Rinaldi
- School of Biomedical Engineering & Imaging Sciences, King's College London, UK; Guy's and St Thomas' Hospital, London, UK
| | - Andrew P King
- School of Biomedical Engineering & Imaging Sciences, King's College London, UK
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The Interventricular Septum: Structure, Function, Dysfunction, and Diseases. J Clin Med 2022; 11:jcm11113227. [PMID: 35683618 PMCID: PMC9181036 DOI: 10.3390/jcm11113227] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 05/25/2022] [Accepted: 06/04/2022] [Indexed: 02/05/2023] Open
Abstract
Vertebrates developed pulmonary circulation and septated the heart into venous and arterial compartments, as the adaptation from aquatic to terrestrial life requires more oxygen and energy. The interventricular septum (IVS) accommodates the ventricular portion of the conduction system and contributes to the mechanical function of both ventricles. Conditions or diseases that affect IVS structure and function (e.g., hypertrophy, defects, other) may lead to ventricular pump failure and/or ventricular arrhythmias with grave consequences. IVS structure and function can be evaluated today using current imaging techniques. Effective therapies can be provided in most cases, although definitions of underlying etiologies may not always be easy, particularly in the elderly due to overlap between genetic and acquired causes of IVS hypertrophy, the most common being IVS abnormality. In this review, state-of-the-art information regarding IVS morphology, physiology, physiopathology, and disease is presented.
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38
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Villegas-Martinez M, Krogh MR, Andersen ØS, Sletten OJ, Wajdan A, Odland HH, Elle OJ, Remme EW. Tracking Early Systolic Motion for Assessing Acute Response to Cardiac Resynchronization Therapy in Real Time. Front Physiol 2022; 13:903784. [PMID: 35721553 PMCID: PMC9201723 DOI: 10.3389/fphys.2022.903784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 05/13/2022] [Indexed: 11/17/2022] Open
Abstract
An abnormal systolic motion is frequently observed in patients with left bundle branch block (LBBB), and it has been proposed as a predictor of response to cardiac resynchronization therapy (CRT). Our goal was to investigate if this motion can be monitored with miniaturized sensors feasible for clinical use to identify response to CRT in real time. Motion sensors were attached to the septum and the left ventricular (LV) lateral wall of eighteen anesthetized dogs. Recordings were performed during baseline, after induction of LBBB, and during biventricular pacing. The abnormal contraction pattern in LBBB was quantified by the septal flash index (SFI) equal to the early systolic shortening of the LV septal-to-lateral wall diameter divided by the maximum shortening achieved during ejection. In baseline, with normal electrical activation, there was limited early-systolic shortening and SFI was low (9 ± 8%). After induction of LBBB, this shortening and the SFI significantly increased (88 ± 34%, p < 0.001). Subsequently, CRT reduced it approximately back to baseline values (13 ± 13%, p < 0.001 vs. LBBB). The study showed the feasibility of using miniaturized sensors for continuous monitoring of the abnormal systolic motion of the LV in LBBB and how such sensors can be used to assess response to pacing in real time to guide CRT implantation.
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Affiliation(s)
- Manuel Villegas-Martinez
- The Intervention Centre, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Magnus Reinsfelt Krogh
- The Intervention Centre, Oslo University Hospital, Oslo, Norway
- Department of Informatics, University of Oslo, Oslo, Norway
| | | | - Ole Jakob Sletten
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Institute for Surgical Research, Oslo University Hospital, Oslo, Norway
- Department of Cardiology and Pediatric Cardiology, Oslo University Hospital, Oslo, Norway
| | - Ali Wajdan
- The Intervention Centre, Oslo University Hospital, Oslo, Norway
- Department of Informatics, University of Oslo, Oslo, Norway
| | - Hans Henrik Odland
- Department of Cardiology and Pediatric Cardiology, Oslo University Hospital, Oslo, Norway
| | - Ole Jakob Elle
- The Intervention Centre, Oslo University Hospital, Oslo, Norway
- Department of Informatics, University of Oslo, Oslo, Norway
| | - Espen W. Remme
- The Intervention Centre, Oslo University Hospital, Oslo, Norway
- Institute for Surgical Research, Oslo University Hospital, Oslo, Norway
- *Correspondence: Espen W. Remme,
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Jones KA, Goodfield NER. Mechanical dyssynchrony and super-response to CRT. J Nucl Cardiol 2022; 29:1175-1177. [PMID: 33403513 DOI: 10.1007/s12350-020-02453-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 11/16/2020] [Indexed: 10/22/2022]
Affiliation(s)
- K A Jones
- Department of Nuclear Cardiology, Glasgow Royal Infirmary, Glasgow, UK.
- School of Physics and Astronomy, University of Glasgow, Glasgow, UK.
| | - N E R Goodfield
- Department of Nuclear Cardiology, Glasgow Royal Infirmary, Glasgow, UK
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Calle S, Timmermans F, De Pooter J. Defining left bundle branch block according to the new 2021 European Society of Cardiology criteria. Neth Heart J 2022; 30:495-498. [PMID: 35503400 PMCID: PMC9613831 DOI: 10.1007/s12471-022-01697-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/23/2022] [Indexed: 11/29/2022] Open
Abstract
Correctly diagnosing left bundle branch block (LBBB) is fundamental, as LBBB occurs frequently in heart failure and may trigger a vicious cycle of progressive left ventricular dysfunction. Moreover, a correct diagnosis of LBBB is pivotal to guide cardiac resynchronisation therapy. Since the LBBB diagnostic criteria were recently updated by the European Society of Cardiology (ESC), we assessed their diagnostic accuracy compared with the previous ESC 2013 definition. We further discuss the complexity of defining LBBB within the context of recent insights into the electromechanical pathophysiology of LBBB.
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Affiliation(s)
- S Calle
- Department of Cardiology, 8-K12, University Hospital Ghent, Ghent, Belgium.
| | - F Timmermans
- Department of Cardiology, 8-K12, University Hospital Ghent, Ghent, Belgium
| | - J De Pooter
- Department of Cardiology, 8-K12, University Hospital Ghent, Ghent, Belgium
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Desynchronization Strain Patterns and Contractility in Left Bundle Branch Block through Computer Model Simulation. J Cardiovasc Dev Dis 2022; 9:jcdd9020053. [PMID: 35200706 PMCID: PMC8875371 DOI: 10.3390/jcdd9020053] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Revised: 01/18/2022] [Accepted: 01/25/2022] [Indexed: 01/24/2023] Open
Abstract
Left bundle branch block (LBBB) is associated with specific septal-to-lateral wall activation patterns which are strongly influenced by the intrinsic left ventricular (LV) contractility and myocardial scar localization. The objective of this study was to propose a computational-model-based interpretation of the different patterns of LV contraction observed in the case of LBBB and preserved contractility or myocardial scarring. Two-dimensional transthoracic echocardiography was used to obtain LV volumes and deformation patterns in three patients with LBBB: (1) a patient with non-ischemic dilated cardiomyopathy, (2) a patient with antero-septal myocardial scar, and (3) a patient with lateral myocardial scar. Scar was confirmed by the distribution of late gadolinium enhancement with cardiac magnetic resonance imaging (cMRI). Model parameters were evaluated manually to reproduce patient-derived data such as strain curves obtained from echocardiographic apical views. The model was able to reproduce the specific strain patterns observed in patients. A typical septal flash with pre-ejection shortening, rebound stretch, and delayed lateral wall activation was observed in the case of non-ischemic cardiomyopathy. In the case of lateral scar, the contractility of the lateral wall was significantly impaired and septal flash was absent. In the case of septal scar, septal flash and rebound stretch were also present as previously described in the literature. Interestingly, the model was also able to simulate the specific contractile properties of the myocardium, providing an excellent localization of LV scar in ischemic patients. The model was able to simulate the electromechanical delay and specific contractility patterns observed in patients with LBBB of ischemic and non-ischemic etiology. With further improvement and validation, this technique might be a useful tool for the diagnosis and treatment planning of heart failure patients needing CRT.
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42
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Classic pattern dyssynchrony is associated with outcome in patients with Fontan circulation. J Am Soc Echocardiogr 2022; 35:513-522. [DOI: 10.1016/j.echo.2022.01.012] [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: 07/06/2021] [Revised: 01/08/2022] [Accepted: 01/21/2022] [Indexed: 11/24/2022]
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43
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Bax JJ, van der Bijl P. Apical Rocking and Septal Flash: Predictors of Secondary Mitral Regurgitation Improvement After Cardiac Resynchronization Therapy. JACC Cardiovasc Imaging 2022; 15:221-223. [PMID: 35144764 DOI: 10.1016/j.jcmg.2021.10.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Accepted: 10/06/2021] [Indexed: 11/25/2022]
Affiliation(s)
- Jeroen J Bax
- Department of Cardiology, Heart Lung Center, Leiden University Medical Centre, Leiden, the Netherlands; Heart Centre, University of Turku and Turku University Hospital, Turku, Finland.
| | - Pieter van der Bijl
- Department of Cardiology, Heart Lung Center, Leiden University Medical Centre, Leiden, the Netherlands
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Abstract
The role of electromechanical dyssynchrony in heart failure gained prominence in literature with the results of trials of cardiac resynchronization therapy (CRT). CRT has shown to significantly decrease heart failure hospitalization and mortality in heart failure patients with dyssynchrony. Current guidelines recommend the use of electrical dyssynchrony based on a QRS > 150 ms and a left bundle branch block pattern on surface electrocardiogram to identify dyssynchrony in patients who will benefit from CRT implantation. However, predicting response to CRT remains a challenge with nearly one-third of patients gaining no benefit from the device. Multiple echocardiographic measures of mechanical dyssynchrony have been studied over the past two decade. However, trials where mechanical dyssynchrony used as an additional or lone criteria for CRT failed to show any benefit in the response to CRT. This shows that a deeper understanding of cardiac mechanics should be applied in the assessment of dyssynchrony. This review discusses the evolving role of imaging techniques in assessing cardiac dyssynchrony and their application in patients considered for device therapy.
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Pujol-López M, Jiménez Arjona R, Guasch E, Doltra A, Borràs R, Roca Luque I, Castel MÁ, Garre P, Ferró E, Niebla M, Carro E, Arbelo E, Sitges M, Tolosana JM, Mont L. Septal Flash Correction with His-Purkinje Pacing Predicts Echocardiographic Response in Resynchronization Therapy. Pacing Clin Electrophysiol 2022; 45:374-383. [PMID: 35015308 PMCID: PMC9303224 DOI: 10.1111/pace.14445] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Revised: 12/27/2021] [Accepted: 01/02/2022] [Indexed: 11/26/2022]
Abstract
Background His‐Purkinje conduction system pacing (HPCSP) has been proposed as an alternative to Cardiac Resynchronization Therapy (CRT); however, predictors of echocardiographic response have not been described in this population. Septal flash (SF), a fast contraction and relaxation of the septum, is a marker of intraventricular dyssynchrony. Methods The study aimed to analyze whether HPCSP corrects SF in patients with CRT indication, and if correction of SF predicts echocardiographic response. This retrospective analysis of prospectively collected data included 30 patients. Left ventricular ejection fraction (LVEF) was measured with echocardiography at baseline and at 6‐month follow‐up. Echocardiographic response was defined as increase in five points in LVEF. Results HPCSP shortened QRS duration by 48 ± 21 ms and SF was significantly decreased (baseline 3.6 ± 2.2 mm vs. HPCSP 1.5 ± 1.5 mm p < .0001). At 6‐month follow‐up, mean LVEF improvement was 8.6% ± 8.7% and 64% of patients were responders. There was a significant correlation between SF correction and increased LVEF (r = .61, p = .004). A correction of ≥1.5 mm (baseline SF – paced SF) had a sensitivity of 81% and 80% specificity to predict echocardiographic response (area under the curve 0.856, p = .019). Conclusion HPCSP improves intraventricular dyssynchrony and results in 64% echocardiographic responders at 6‐month follow‐up. Dyssynchrony improvement with SF correction may predict echocardiographic response at 6‐month follow‐up.
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Affiliation(s)
- Margarida Pujol-López
- Institut Clínic Cardiovascular (ICCV), Hospital Clínic, Universitat de Barcelona, Catalonia, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia, Spain
| | - Rafael Jiménez Arjona
- Institut Clínic Cardiovascular (ICCV), Hospital Clínic, Universitat de Barcelona, Catalonia, Spain
| | - Eduard Guasch
- Institut Clínic Cardiovascular (ICCV), Hospital Clínic, Universitat de Barcelona, Catalonia, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia, Spain.,Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - Adelina Doltra
- Institut Clínic Cardiovascular (ICCV), Hospital Clínic, Universitat de Barcelona, Catalonia, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia, Spain
| | - Roger Borràs
- Institut Clínic Cardiovascular (ICCV), Hospital Clínic, Universitat de Barcelona, Catalonia, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia, Spain
| | - Ivo Roca Luque
- Institut Clínic Cardiovascular (ICCV), Hospital Clínic, Universitat de Barcelona, Catalonia, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia, Spain
| | - M Ángeles Castel
- Institut Clínic Cardiovascular (ICCV), Hospital Clínic, Universitat de Barcelona, Catalonia, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia, Spain.,Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - Paz Garre
- Institut Clínic Cardiovascular (ICCV), Hospital Clínic, Universitat de Barcelona, Catalonia, Spain
| | - Elisenda Ferró
- Medtronic Iberica, Madrid, Spain.,Fundació Clínic per a la Recerca Biomèdica (FCRB), Barcelona, Catalonia, Spain
| | - Mireia Niebla
- Institut Clínic Cardiovascular (ICCV), Hospital Clínic, Universitat de Barcelona, Catalonia, Spain
| | - Esther Carro
- Institut Clínic Cardiovascular (ICCV), Hospital Clínic, Universitat de Barcelona, Catalonia, Spain
| | - Elena Arbelo
- Institut Clínic Cardiovascular (ICCV), Hospital Clínic, Universitat de Barcelona, Catalonia, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia, Spain.,Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - Marta Sitges
- Institut Clínic Cardiovascular (ICCV), Hospital Clínic, Universitat de Barcelona, Catalonia, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia, Spain.,Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - José M Tolosana
- Institut Clínic Cardiovascular (ICCV), Hospital Clínic, Universitat de Barcelona, Catalonia, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia, Spain.,Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - Lluís Mont
- Institut Clínic Cardiovascular (ICCV), Hospital Clínic, Universitat de Barcelona, Catalonia, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia, Spain.,Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
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46
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Hamdy RM, Osama H, Fereig HM. Evaluation of Cardiac Mechanical Dyssynchrony in Heart Failure Patients Using Current Echo-Doppler Modalities. J Cardiovasc Imaging 2022; 30:307-319. [PMID: 36280273 PMCID: PMC9592249 DOI: 10.4250/jcvi.2022.0061] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Revised: 07/13/2022] [Accepted: 07/19/2022] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Current guidelines indicate electrical dyssynchrony as the major criteria for selecting patients for cardiac resynchronization therapy, and 25–35% of patients exhibit unfavorable responses to cardiac resynchronization therapy (CRT). We aimed to evaluate different cardiac mechanical dyssynchrony parameters in heart failure patients using current echo-Doppler modalities and we analyzed their association with electrical dyssynchrony. METHODS The study included 120 heart failure with reduced ejection fraction (HFrEF) who underwent assessments for left ventricular mechanical dyssynchrony (LVMD) and interventricular mechanical dyssynchrony (IVMD). RESULTS Patients were classified according to QRS duration: group I with QRS < 120 ms, group II with QRS 120–149 ms, and group III with QRS ≥ 150 ms. Group III had significantly higher IVMD, LVMD indices, TS-SD speckle-tracking echocardiography (STE) 12 segments (standard deviation of time to peak longitudinal strain speckle tracking echocardiography in 12 LV-segments), and LVMD score compared with group I and group II. Group II and group III were classified according to QRS morphology into left bundle branch block (LBBB) and non-LBBB subgroups. LVMD score, TS-SD 12 TDI, and TS-SD 12 STE had good correlations with QRS duration. CONCLUSIONS HFrEF patients with wide QRS duration (> 150 ms) had more evident LVMD compared with patients with narrow or intermediate QRS. Those patients with intermediate QRS duration (120–150 ms) had substantial LVMD assessed by both TDI and 2D STE, regardless of QRS morphology. Subsequently, we suggest that LVMD indices might be employed as additive criteria to predict CRT response in that patient subgroup. Electrical and mechanical dyssynchrony were strongly correlated in HFrEF patients.
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Affiliation(s)
- Rehab M. Hamdy
- Department of Cardiology, Faculty of Medicine (for girls), Al-Azhar University, Cairo, Egypt
| | - Hend Osama
- Department of Cardiology, Faculty of Medicine (for girls), Al-Azhar University, Cairo, Egypt
| | - Hanaa M. Fereig
- Department of Cardiology, Faculty of Medicine (for girls), Al-Azhar University, Cairo, Egypt
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47
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OUP accepted manuscript. Eur Heart J Cardiovasc Imaging 2022; 23:741-742. [DOI: 10.1093/ehjci/jeac067] [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: 11/12/2022] Open
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48
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Wouters PC, van Everdingen WM, Vernooy K, Geelhoed B, Allaart CP, Rienstra M, Maass AH, Vos MA, Prinzen FW, Meine M, Cramer MJ. Does mechanical dyssynchrony in addition to QRS area ensure sustained response to cardiac resynchronization therapy? Eur Heart J Cardiovasc Imaging 2021; 23:1628-1635. [PMID: 34871385 PMCID: PMC9671288 DOI: 10.1093/ehjci/jeab264] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Accepted: 11/23/2021] [Indexed: 11/27/2022] Open
Abstract
Aims Judicious patient selection for cardiac resynchronization therapy (CRT) may further enhance treatment response. Progress has been made by using improved markers of electrical dyssynchrony and mechanical discoordination, using QRSAREA, and systolic rebound stretch of the septum (SRSsept) or systolic stretch index (SSI), respectively. To date, the relation between these measurements has not yet been investigated. Methods and results A total of 240 CRT patients were prospectively enrolled from six centres. Patients underwent standard 12-lead electrocardiography, and echocardiography, at baseline, 6-month, and 12-month follow-up. QRSAREA was derived using vectorcardiography, and SRSsept and SSI were measured using strain-analysis. Reverse remodelling was measured as the relative decrease in left ventricular end-systolic volume, indexed to body surface area (ΔLVESVi). Sustained response was defined as ≥15% decrease in LVESVi, at both 6- and 12-month follow-up. QRSAREA and SRSsept were both strong, multivariable adjusted, variables associated with reverse remodelling. SRSsept was associated with response, but only in patients with QRSAREA ≥ 120 μVs (AUC = 0.727 vs. 0.443). Combined presence of SRSsept ≥ 2.5% and QRSAREA ≥ 120 μVs significantly increased reverse remodelling compared with high QRSAREA alone (ΔLVESVi 38 ± 21% vs. 22 ± 21%). As a result, 92% of left bundle branch block (LBBB)-patients with combined electrical and mechanical dysfunction were ‘sustained’ volumetric responders, as opposed to 51% with high QRSAREA alone. Conclusion Parameters of mechanical dyssynchrony are better associated with response in the presence of a clear underlying electrical substrate. Combined presence of high SRSsept and QRSAREA, but not high QRSAREA alone, ensures a sustained response after CRT in LBBB patients.
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Affiliation(s)
- Philippe C Wouters
- Department of Cardiology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - Wouter M van Everdingen
- Department of Cardiology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - Kevin Vernooy
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre+ (MUMC+), 6229 HX Maastricht, The Netherlands.,Department of Cardiology, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands
| | - Bastiaan Geelhoed
- Department of Cardiology, Thoraxcentre, University of Groningen, University Medical Center Groningen, 9713 GZ Groningen, The Netherlands
| | - Cornelis P Allaart
- Department of Cardiology, Amsterdam University Medical Center, Location VU University Medical Center, 1081 HV Amsterdam, The Netherlands
| | - Michiel Rienstra
- Department of Cardiology, Thoraxcentre, University of Groningen, University Medical Center Groningen, 9713 GZ Groningen, The Netherlands
| | - Alexander H Maass
- Department of Cardiology, Thoraxcentre, University of Groningen, University Medical Center Groningen, 9713 GZ Groningen, The Netherlands
| | - Marc A Vos
- Department of Medical Physiology, University of Utrecht, 3584 CM Utrecht, The Netherlands
| | - Frits W Prinzen
- Department of Physiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, 6229 ER Masstricht, The Netherlands
| | - Mathias Meine
- Department of Cardiology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - Maarten J Cramer
- Department of Cardiology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
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Gu H, Sidhu BS, Fang L, Webb J, Jackson T, Claridge S, Einarsen E, Razavi R, Papageorgiou N, Chow A, Bhattacharyya S, Chowienczyk P, Rinaldi CA. First-Phase Ejection Fraction Predicts Response to Cardiac Resynchronization Therapy and Adverse Outcomes. JACC Cardiovasc Imaging 2021; 14:2275-2285. [PMID: 34886993 DOI: 10.1016/j.jcmg.2021.05.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 05/04/2021] [Accepted: 05/14/2021] [Indexed: 12/12/2022]
Abstract
OBJECTIVES The aim of this study was to examine the value of first-phase ejection fraction (EF1), to predict response to cardiac resynchronization therapy (CRT) and clinical outcomes after CRT. BACKGROUND CRT is an important treatment for patients with chronic heart failure. However, even in carefully selected cases, up to 40% of patients fail to respond. EF1, the ejection fraction up to the time of maximal ventricular contraction, is a novel sensitive echocardiographic measure of early systolic function and might relate to response to CRT. METHODS An initial retrospective study was performed in 197 patients who underwent CRT between 2009 and 2018 and were followed to determine clinical outcomes at King's Health Partners in London. A validation study (n = 100) was performed in patients undergoing CRT at Barts Heart Centre in London. RESULTS Volumetric response rate (reduction in end-systolic volume ≥15%) was 92.3% and 12.1% for those with EF1 in the highest and lowest tertiles (P < 0.001). A cutoff value of 11.9% for EF1 had >85% sensitivity and specificity for prediction of response to CRT; on multivariate binary logistic regression analysis incorporating previously defined predictors, EF1 was the strongest predictor of response (odds ratio [OR]: 1.56 per 1% change in EF1; 95% CI: 1.37-1.78; P < 0.001). EF1 was also the strongest predictor of improvement in clinical composite score (OR: 1.11; 95% CI: 1.04-1.19; P = 0.001). Improvement in EF1 at 6 months after CRT implantation (6.5% ± 5.8% vs 1.8% ± 4.3% in responders vs nonresponders; P < 0.001) was the best predictor of heart failure rehospitalization and death after median follow-up period of 20.3 months (HR: 0.81; 95% CI: 0.73-0.90; P < 0.001). In the validation cohort, EF1 was a similarly 1strong predictor of response (OR: 1.45; 95% CI: 1.23-1.70; P < 0.001) as in the original cohort. CONCLUSIONS EF1 is a promising marker to identify patients likely to respond to CRT.
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Affiliation(s)
- Haotian Gu
- British Heart Foundation Centre, King's College London, London, United Kingdom
| | - Baldeep S Sidhu
- Cardiology Department, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Lingyun Fang
- British Heart Foundation Centre, King's College London, London, United Kingdom
| | - Jessica Webb
- Cardiology Department, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom; Imaging Sciences and Biomedical Engineering, King's College London, London, United Kingdom
| | - Tom Jackson
- Imaging Sciences and Biomedical Engineering, King's College London, London, United Kingdom
| | - Simon Claridge
- Cardiology Department, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Eigir Einarsen
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Reza Razavi
- Imaging Sciences and Biomedical Engineering, King's College London, London, United Kingdom
| | | | - Anthony Chow
- Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom
| | | | - Phil Chowienczyk
- British Heart Foundation Centre, King's College London, London, United Kingdom.
| | - Christopher A Rinaldi
- Cardiology Department, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
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50
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Left Bundle Branch Block: Characterization, Definitions, and Recent Insights into Conduction System Physiology. Card Electrophysiol Clin 2021; 13:671-684. [PMID: 34689894 DOI: 10.1016/j.ccep.2021.07.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Left bundle branch block (LBBB) is not just a simple electrocardiogram alteration. The intricacies of this general terminology go beyond simple conduction block. This review puts together current knowledge on the historical concept of LBBB, clinical significance, and recent insights into the pathophysiology of human LBBB. LBBB is an entity that affects patient diagnosis (primary conduction disease, secondary to underlying pathology or iatrogenic), treatment (cardiac resynchronization therapy or conduction system pacing for heart failure), and prognosis. Recruiting the left bundle branch with conduction system pacing depends on the complex interaction between anatomy, site of pathophysiology, and delivery tools.
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