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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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Dell'Era G, Ghiglieno C, Degiovanni A, De Vecchi F, Porcellini S, Santagostino M, Veroli A, D'Amico A, Spinoni EG, Patti G. Early effects of left bundle branch area pacing on ventricular activation by speckle tracking echocardiography. J Interv Card Electrophysiol 2024; 67:341-351. [PMID: 37599321 DOI: 10.1007/s10840-023-01616-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 08/01/2023] [Indexed: 08/22/2023]
Abstract
BACKGROUND Left bundle branch area pacing (LBBAP) is an emerging cardiac pacing modality that preserves fast electrical activation of the ventricles and provides very good electrical measures. Little is known on mechanical ventricular activation during this pacing modality. METHODS We prospectively enrolled patients receiving LBBAP. Electrocardiographic and electrical parameters were evaluated at implantation, < 24 h and 3 months. Transthoracic echocardiography with strain analysis was performed at baseline and after 3 months, when ventricular mechanical activation and synchrony were analyzed by time-to-peak standard deviation (TPSD) of strain curves for both ventricles. Intraventricular left ventricular (LV) dyssynchrony was investigated by LV TPSD and interventricular dyssynchrony by left ventricle-right ventricle TPSD (LV-RV TPSD). RESULTS We screened 58 patients with permanent pacing indication who attempted LBBAP. Procedural success was obtained in 56 patients (97%). Strain data were available in 50 patients. QRS duration was 124.1 ± 30.7 ms at baseline, while paced QRS duration was 107.7 ± 13.6 ms (p < 0.001). At 3 months after LBBAP, left ventricular ejection fraction (LVEF) increased from 52.9 ± 10.6% at baseline to 56.9 ± 8.4% (p = 0.004) and both intraventricular LV dyssynchrony and interventricular dyssynchrony significantly improved (LV TPSD reduction from 38.2 (13.6-53.9) to 15.1 (8.3-31.5), p < 0.001; LV-RV TPSD from 27.9 (10.2-41.5) to 13.9 (4.3-28.7), p = 0.001). Ameliorations with LBBAP were consistent in all subgroups, irrespective of baseline QRS duration, types of intraventricular conduction abnormalities, and LVEF. CONCLUSIONS Echocardiographic strain analysis shows that LBBAP determines a fast and synchronous biventricular contraction with a stereotype mechanical activation, regardless of baseline QRS duration, pattern, and LV function.
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Affiliation(s)
- Gabriele Dell'Era
- Clinica Cardiologica, Dipartimento Toraco-Cardio-Vascolare, Ospedale Maggiore Della Carità Di Novara, Corso Mazzini 18, 28100, Novara, Italy.
| | - Chiara Ghiglieno
- Clinica Cardiologica, Dipartimento Toraco-Cardio-Vascolare, Ospedale Maggiore Della Carità Di Novara, Corso Mazzini 18, 28100, Novara, Italy
- Università del Piemonte Orientale Amedeo Avogadro, Vercelli, Italy
| | - Anna Degiovanni
- Clinica Cardiologica, Dipartimento Toraco-Cardio-Vascolare, Ospedale Maggiore Della Carità Di Novara, Corso Mazzini 18, 28100, Novara, Italy
| | - Federica De Vecchi
- Clinica Cardiologica, Dipartimento Toraco-Cardio-Vascolare, Ospedale Maggiore Della Carità Di Novara, Corso Mazzini 18, 28100, Novara, Italy
| | - Stefano Porcellini
- Clinica Cardiologica, Dipartimento Toraco-Cardio-Vascolare, Ospedale Maggiore Della Carità Di Novara, Corso Mazzini 18, 28100, Novara, Italy
| | - Matteo Santagostino
- Clinica Cardiologica, Dipartimento Toraco-Cardio-Vascolare, Ospedale Maggiore Della Carità Di Novara, Corso Mazzini 18, 28100, Novara, Italy
| | - Alessandro Veroli
- Clinica Cardiologica, Dipartimento Toraco-Cardio-Vascolare, Ospedale Maggiore Della Carità Di Novara, Corso Mazzini 18, 28100, Novara, Italy
- Università del Piemonte Orientale Amedeo Avogadro, Vercelli, Italy
| | - Anthea D'Amico
- Clinica Cardiologica, Dipartimento Toraco-Cardio-Vascolare, Ospedale Maggiore Della Carità Di Novara, Corso Mazzini 18, 28100, Novara, Italy
- Università del Piemonte Orientale Amedeo Avogadro, Vercelli, Italy
| | - Enrico Guido Spinoni
- Clinica Cardiologica, Dipartimento Toraco-Cardio-Vascolare, Ospedale Maggiore Della Carità Di Novara, Corso Mazzini 18, 28100, Novara, Italy
- Università del Piemonte Orientale Amedeo Avogadro, Vercelli, Italy
| | - Giuseppe Patti
- Clinica Cardiologica, Dipartimento Toraco-Cardio-Vascolare, Ospedale Maggiore Della Carità Di Novara, Corso Mazzini 18, 28100, Novara, Italy
- Università del Piemonte Orientale Amedeo Avogadro, Vercelli, Italy
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Ramdat Misier NL, Moore JP, Nguyen HH, Lloyd MS, Dubin AM, Mah DY, Czosek RJ, Khairy P, Chang PM, Nielsen JC, Aydin A, Pilcher TA, O'Leary ET, Shivkumar K, de Groot NMS. Long-Term Outcomes of Cardiac Resynchronization Therapy in Patients With Repaired Tetralogy of Fallot: A Multicenter Study. Circ Arrhythm Electrophysiol 2024; 17:e012363. [PMID: 38344811 DOI: 10.1161/circep.123.012363] [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: 08/01/2023] [Accepted: 01/17/2024] [Indexed: 03/21/2024]
Abstract
BACKGROUND A growing number of patients with tetralogy of Fallot develop left ventricular systolic dysfunction and heart failure, in addition to right ventricular dysfunction. Although cardiac resynchronization therapy (CRT) is an established treatment option, the effect of CRT in this population is still not well defined. This study aimed to investigate the early and late efficacy, survival, and safety of CRT in patients with tetralogy of Fallot. METHODS Data were analyzed from an observational, retrospective, multicenter cohort, initiated jointly by the Pediatric and Congenital Electrophysiology Society and the International Society of Adult Congenital Heart Disease. Twelve centers contributed baseline and longitudinal data, including vital status, left ventricular ejection fraction (LVEF), QRS duration, and NYHA functional class. Outcomes were analyzed at early (3 months), intermediate (1 year), and late follow-up (≥2 years) after CRT implantation. RESULTS A total of 44 patients (40.3±19.2 years) with tetralogy of Fallot and CRT were enrolled. Twenty-nine (65.9%) patients had right ventricular pacing before CRT upgrade. The left ventricular ejection fraction improved from 32% [24%-44%] at baseline to 42% [32%-50%] at early follow-up (P<0.001) and remained improved from baseline thereafter (P≤0.002). The QRS duration decreased from 180 [160-205] ms at baseline to 152 [133-182] ms at early follow-up (P<0.001) and remained decreased at intermediate and late follow-up (P≤0.001). Patients with upgraded CRT had consistent improvement in left ventricular ejection fraction and QRS duration at each time point (P≤0.004). Patients had a significantly improved New York Heart Association functional class after CRT implantation at each time point compared with baseline (P≤0.002). The transplant-free survival rates at 3, 5, and 8 years after CRT implantation were 85%, 79%, and 73%. CONCLUSIONS In patients with tetralogy of Fallot treated with CRT consistent improvement in QRS duration, left ventricular ejection fraction, New York Heart Association functional class, and reasonable long-term survival were observed. The findings from this multicenter study support the consideration of CRT in this unique population.
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Affiliation(s)
- Nawin L Ramdat Misier
- Department of Cardiology, Erasmus Medical Center, Rotterdam , The Netherlands (N.L.R.M., N.M.S.d.G.)
| | - Jeremy P Moore
- Ahmanson/University of California Los Angeles Adult Congenital Heart Disease Center, Los Angeles, CA (J.P.M., K.S.)
| | - Hoang H Nguyen
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX (H.H.N.)
| | - Michael S Lloyd
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, GA (M.S.L.)
| | - Anne M Dubin
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto CA (A.M.D.)
| | - Douglas Y Mah
- Department of Cardiology, Boston Children's Hospital and Harvard Medical School, Boston MA (D.Y.M., E.T.O.)
| | - Richard J Czosek
- Division of Pediatric Cardiology, Department of Pediatrics, The Heart Institute at Cincinnati Children's Hospital Medical Center, Cincinnati OH (R.J.C.)
| | - Paul Khairy
- Electrophysiology Service and Adult Congenital Heart Center, Montreal Heart Institute, Université de Montréal, Montreal Quebec, Canada (P.K.)
| | - Philip M Chang
- Congenital Heart Center, University of Florida Health, Gainesville, FL (P.M.C.)
| | - Jens C Nielsen
- Department of Clinical Medicine, Aarhus University, Aarhus Denmark (J.C.N.)
- Department of Cardiology, Aarhus University Hospital, Aarhus Denmark (J.C.N.)
| | - Alper Aydin
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario Canada (A.A.)
| | - Thomas A Pilcher
- Division of Pediatric Cardiology, Department of Internal Medicine, University of Utah, Salt Lake City UT (T.A.P.)
| | - Edward T O'Leary
- Department of Cardiology, Boston Children's Hospital and Harvard Medical School, Boston MA (D.Y.M., E.T.O.)
| | - Kalyanam Shivkumar
- Ahmanson/University of California Los Angeles Adult Congenital Heart Disease Center, Los Angeles, CA (J.P.M., K.S.)
| | - Natasja M S de Groot
- Department of Cardiology, Erasmus Medical Center, Rotterdam , The Netherlands (N.L.R.M., N.M.S.d.G.)
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Sakaguchi Y, Izumi D, Wada R, Akagawa R, Suzuki N, Hakamata T, Ikami Y, Hasegaw Y, Otsuki S, Yagihara N, Iijima K, Inomata T. Predictors of long-term survival in Japanese patients with heart failure with reduced ejection fraction (HFrEF) treated with cardiac resynchronization therapy-defibrillators (CRT-D). Pacing Clin Electrophysiol 2023; 46:1484-1490. [PMID: 37864809 DOI: 10.1111/pace.14848] [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: 06/25/2023] [Revised: 09/24/2023] [Accepted: 10/07/2023] [Indexed: 10/23/2023]
Abstract
BACKGROUND Reports on the factors predicting long-term survival of CRT-D cases from Western countries are increasing, however, those from Asia including Japan are still sparse. We aimed to clarify the factors predicting long-term survival of Japanese CRT-D cases. METHODS We retrospectively analyzed consecutive 133 patients who underwent CRT-D implantation between 2006 and 2021. We compared clinical factors between patients who died within 5 years after implantation (short-survival group: n = 31) and who had survived for more than 5 years (long-survival group: n = 36) after implantation. RESULTS Major underlying heart diseases were dilated cardiomyopathy (45%) and ischemic heart disease (12%). There was no difference between the short-survival group and the long-survival group in incidence of CLBBB (32% vs. 30%), whereas CRBBB was more common in the short-survival group (26% vs. 0%, p = .004). Mechanical dyssynchrony at implantation was more frequent in the long-survival group (48% vs. 78%, p = .02). The incidence of response to CRT at 1 year after implantation was higher in long-survival group (19% vs. 50%, p = .02). Multiple logistic regression analysis identified NYHA class, mechanical dyssynchrony at implantation, and response at one year as predictors of long-term survival. CONCLUSIONS In Japanese CRT-D cases, lower NHYA class, preexisting mechanical dyssynchrony, and 1-year response to CRT predict long-term survival.
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Affiliation(s)
- Yuta Sakaguchi
- Department of Cardiovascular Medicine, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Daisuke Izumi
- Department of Cardiovascular Medicine, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Rhythm Wada
- Department of Cardiovascular Medicine, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Rie Akagawa
- Department of Cardiovascular Medicine, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Naomasa Suzuki
- Department of Cardiovascular Medicine, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Takahiro Hakamata
- Department of Cardiovascular Medicine, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Yasuhiro Ikami
- Department of Cardiovascular Medicine, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Yuki Hasegaw
- Department of Cardiovascular Medicine, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Sou Otsuki
- Department of Cardiovascular Medicine, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Nobue Yagihara
- Department of Cardiovascular Medicine, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Kenichi Iijima
- Department of Cardiovascular Medicine, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Takayuki Inomata
- Department of Cardiovascular Medicine, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
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Chen X, Li X, Bai Y, Wang J, Qin S, Bai J, Wang W, Liang Y, Chen H, Su Y, Ge J. Electrical Resynchronization and Clinical Outcomes During Long-Term Follow-Up in Intraventricular Conduction Delay Patients Applied Left Bundle Branch Pacing-Optimized Cardiac Resynchronization Therapy. Circ Arrhythm Electrophysiol 2023; 16:e011761. [PMID: 37577815 DOI: 10.1161/circep.122.011761] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Accepted: 08/03/2023] [Indexed: 08/15/2023]
Abstract
BACKGROUND Left bundle branch-optimized cardiac resynchronization therapy (LOT-CRT) has shown encouraging results for QRS duration reduction and heart function improvement. However, the feasibility and efficacy of LOT-CRT have not been well established in intraventricular conduction delay patients. This study aims to assess and compare the efficacy and clinical outcome of CRT based on left bundle branch pacing, combined with coronary sinus left ventricular pacing (LOT-CRT) with CRT via biventricular pacing (BiV-CRT) in intraventricular conduction delay patients indicated for CRT. METHODS Consecutive patients with intraventricular conduction delay and CRT indications were assigned nonrandomized to LOT-CRT (n=30) or BiV-CRT (n=55). Addition of the left bundle branch pacing (or coronary venous) lead was at the discretion of the implanting physician guided by suboptimal paced QRS complex and on clinical grounds. Echocardiographic parameters and clinical characteristics were accessed at baseline and during 2-years' follow-up. RESULTS Success rate for LOT-CRT and BiV-CRT was 96.8% and 96.4%. LOT-CRT had greater reduction of QRS duration compared with BiV-CRT (42.7±17.4 ms versus 21.9±21.5 ms; P<0.001). Higher left ventricular ejection fraction was also achieved in LOT-CRT than BiV-CRT at 6-month (36.7±9.8% versus 30.5±6.4%; P<0.05), 12-month (34.8±7.6% versus 30.3±6.2%; P<0.05), 18-month (36.3±7.9% versus 28.1±6.6%; P<0.005), and 24-month follow-up (37±9.5% versus 30.5±7%; P<0.05). Adverse clinical outcomes including heart failure rehospitalization and mortality were lower in LOT-CRT group for 24 months follow-up (hazard ratio, 0.33; P=0.035). CONCLUSIONS LOT-CRT improves ventricular electrical synchrony and may provide greater clinical outcomes as compared with BiV-CRT in intraventricular conduction delay patients. These findings need further evaluation in future randomized controlled trials.
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Affiliation(s)
- Xueying Chen
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases; National Clinical Research Center for Interventional Medicine, China
| | - Xiao Li
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases; National Clinical Research Center for Interventional Medicine, China
| | - Yingnan Bai
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases; National Clinical Research Center for Interventional Medicine, China
| | - Jingfeng Wang
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases; National Clinical Research Center for Interventional Medicine, China
| | - Shengmei Qin
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases; National Clinical Research Center for Interventional Medicine, China
| | - Jin Bai
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases; National Clinical Research Center for Interventional Medicine, China
| | - Wei Wang
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases; National Clinical Research Center for Interventional Medicine, China
| | - Yixiu Liang
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases; National Clinical Research Center for Interventional Medicine, China
| | - Haiyan Chen
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases; National Clinical Research Center for Interventional Medicine, China
| | - Yangang Su
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases; National Clinical Research Center for Interventional Medicine, China
| | - Junbo Ge
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases; National Clinical Research Center for Interventional Medicine, China
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Zand S, Sadeghian H, Kazemisaid A, Lotfi-Tokaldany M, Jalali A, Sardari A. Response to Cardiac Resynchronization Therapy in Cardiomyopathy Patients with Right Bundle Branch Block. J Tehran Heart Cent 2023; 18:109-114. [PMID: 37637276 PMCID: PMC10459338 DOI: 10.18502/jthc.v18i2.13320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 12/14/2023] [Indexed: 08/29/2023] Open
Abstract
Background The use of cardiac resynchronization therapy (CRT) in heart failure patients with right bundle branch block (RBBB) is under debate. We present early and late echocardiographic characteristics of a series of heart failure patients with RBBB who underwent CRT. Methods In this retrospective descriptive study, 18 patients with RBBB in the surface electrocardiogram underwent CRT between 2005 and 2015. All the patients had the New York Heart Association functional class III/IV, a left ventricular ejection fraction (LVEF) ≤35%, and a QRS duration ≥120 milliseconds. The median follow-up duration was 19 months. The echocardiographic response was based on a ≥5% increase in LVEF. Results Within 48 hours after CRT implantation, LVEF increased from 24.58%±7.08% before to 28.46±8.91% after CRT (P=0.005) and to 30.00±9.44% at follow-up (P=0.008). Among the 18 patients, 12 (66.7%) were responders within 48 hours after CRT. The following baseline echocardiographic parameters were higher in the responders than in those without an increased LVEF, although the difference did not reach statistical significance: septal-to-lateral wall delay (48.33±33.53 vs 43.33±38.82 ms), anteroseptal-to-posterior wall delay (41.7±1.75 vs 38.33±18.35 ms), and interventricular mechanical delay (48.50±21.13 vs 31.17±19.93 ms). The mean QRS duration was higher in the responders than in the non-responders (183.58±40.69 vs 169.00±27.36 ms). Death was reported in 3 out of the 18 patients (16.7%) at follow-up. The 3 deceased patients had a higher baseline interventricular mechanical delay than those who survived. Conclusion Our results indicated that patients with RBBB might benefit from CRT. Further, patients with higher intra and interventricular dyssynchrony and a wider QRS may show better responses.
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Affiliation(s)
- Sara Zand
- Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Hakimeh Sadeghian
- Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Ali Kazemisaid
- Department of Electrophysiology, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Masoumeh Lotfi-Tokaldany
- Tehran Heart Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Arash Jalali
- Tehran Heart Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Akram Sardari
- Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
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7
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Strocchi M, Gillette K, Neic A, Elliott MK, Wijesuriya N, Mehta V, Vigmond EJ, Plank G, Rinaldi CA, Niederer SA. Comparison between conduction system pacing and cardiac resynchronization therapy in right bundle branch block patients. Front Physiol 2022; 13:1011566. [PMID: 36213223 PMCID: PMC9532840 DOI: 10.3389/fphys.2022.1011566] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Accepted: 08/29/2022] [Indexed: 11/20/2022] Open
Abstract
A significant number of right bundle branch block (RBBB) patients receive cardiac resynchronization therapy (CRT), despite lack of evidence for benefit in this patient group. His bundle (HBP) and left bundle pacing (LBP) are novel CRT delivery methods, but their effect on RBBB remains understudied. We aim to compare pacing-induced electrical synchrony during conventional CRT, HBP, and LBP in RBBB patients with different conduction disturbances, and to investigate whether alternative ways of delivering LBP improve response to pacing. We simulated ventricular activation on twenty-four four-chamber heart geometries each including a His-Purkinje system with proximal right bundle branch block (RBBB). We simulated RBBB combined with left anterior and posterior fascicular blocks (LAFB and LPFB). Additionally, RBBB was simulated in the presence of slow conduction velocity (CV) in the myocardium, left ventricular (LV) or right ventricular (RV) His-Purkinje system, and whole His-Purkinje system. Electrical synchrony was measured by the shortest interval to activate 90% of the ventricles (BIVAT-90). Compared to baseline, HBP significantly improved activation times for RBBB alone (BIVAT-90: 66.9 ± 5.5 ms vs. 42.6 ± 3.8 ms, p < 0.01), with LAFB (69.5 ± 5.0 ms vs. 58.1 ± 6.2 ms, p < 0.01), with LPFB (81.8 ± 6.6 ms vs. 62.9 ± 6.2 ms, p < 0.01), with slow myocardial CV (119.4 ± 11.4 ms vs. 97.2 ± 10.0 ms, p < 0.01) or slow CV in the whole His-Purkinje system (102.3 ± 7.0 ms vs. 75.5 ± 5.2 ms, p < 0.01). LBP was only effective in RBBB cases if combined with anodal capture of the RV septum myocardium (BIVAT-90: 66.9 ± 5.5 ms vs. 48.2 ± 5.2 ms, p < 0.01). CRT significantly reduced activation times in RBBB in the presence of severely slow RV His-Purkinje CV (95.1 ± 7.9 ms vs. 84.3 ± 9.3 ms, p < 0.01) and LPFB (81.8 ± 6.6 ms vs. CRT: 72.9 ± 8.6 ms, p < 0.01). Both CRT and HBP were ineffective with severely slow CV in the LV His-Purkinje system. HBP is effective in RBBB patients with otherwise healthy myocardium and Purkinje system, while CRT and LBP are ineffective. Response to LBP improves when LBP is combined with RV septum anodal capture. CRT is better than HBP only in patients with severely slow CV in the RV His-Purkinje system, while CV slowing of the whole His-Purkinje system and the myocardium favor HBP over CRT.
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Affiliation(s)
- Marina Strocchi
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, United Kingdom
| | - Karli Gillette
- BioTechMed-Graz, Graz, Austria
- Gottfried Schatz Research Center, Medical University of Graz, Graz, Austria
| | | | - Mark K. Elliott
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, United Kingdom
- Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Nadeev Wijesuriya
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, United Kingdom
- Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Vishal Mehta
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, United Kingdom
- Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | | | - Gernot Plank
- BioTechMed-Graz, Graz, Austria
- Gottfried Schatz Research Center, Medical University of Graz, Graz, Austria
| | - Christopher A. Rinaldi
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, United Kingdom
- Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Steven A. Niederer
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, United Kingdom
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Gowani ZS, Tomashitis B, Vo CN, Field ME, Gold MR. Role of Electrical Delay in Cardiac Resynchronization Therapy Response. Card Electrophysiol Clin 2022; 14:233-241. [PMID: 35715081 DOI: 10.1016/j.ccep.2021.12.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Traditionally, left ventricular (LV) lead position was guided by anatomic criteria of pacing from the lateral wall of the LV. However, large trials showed little effect of LV lead position on outcomes, other than noting worse outcomes with apical positions. Given the poor correlation of cardiac resynchronization therapy (CRT) outcomes with anatomically guided LV lead placement, focus shifted toward more physiologic predictors such as targeting the areas of delayed mechanical and electrical activation. Measures of left ventricular delay and interventricular delay are strong predictors of CRT response.
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Affiliation(s)
- Zain S Gowani
- Department of Medicine, Medical University of South Carolina, 25 Courtenay Drive, MS-492, Charleston, SC 29425, USA
| | - Brett Tomashitis
- Department of Medicine, Medical University of South Carolina, 25 Courtenay Drive, MS-492, Charleston, SC 29425, USA
| | - Chau N Vo
- Department of Medicine, Medical University of South Carolina, 25 Courtenay Drive, MS-492, Charleston, SC 29425, USA
| | - Michael E Field
- Department of Medicine, Medical University of South Carolina, 25 Courtenay Drive, MS-492, Charleston, SC 29425, USA
| | - Michael R Gold
- Department of Medicine, Medical University of South Carolina, 25 Courtenay Drive, MS-492, Charleston, SC 29425, USA.
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Novel electrocardiographic dyssynchrony criteria that may improve patient selection for cardiac resynchronization therapy. J Geriatr Cardiol 2022; 19:31-43. [PMID: 35233221 PMCID: PMC8832041 DOI: 10.11909/j.issn.1671-5411.2022.01.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Cardiac resynchronization therapy (CRT) is an evidence-based effective therapy of symptomatic heart failure with reduced ejection fraction refractory to optimal medical treatment associated with intraventricular conduction disturbance, that results in electrical dyssynchrony and further deterioration of systolic ventricular function. However, the non-response rate to CRT is still 20%−40%, which can be decreased by better patient selection. The main determinant of CRT outcome is the presence or absence of significant ventricular dyssynchrony and the ability of the applied CRT technique to eliminate it. The current guidelines recommend the determination of QRS morphology and QRS duration and the measurement of left ventricular ejection fraction for patient selection for CRT. However, QRS morphology and QRS duration are not perfect indicators of electrical dyssynchrony, which is the cause of the not negligible non-response rate to CRT and the missed CRT implantation in a significant number of patients who have the appropriate substrate for CRT. Using imaging modalities, many ventricular dyssynchrony criteria were devised for the detection of mechanical dyssynchrony, but their utility in patient selection for CRT is not yet proven, therefore their use is not recommended for this purpose. Moreover, CRT can eliminate only mechanical dyssynchrony due to underlying electrical dyssynchrony, for this reason ECG has a greater role in the detection of ventricular dyssynchrony than imaging modalities. To improve assessment of electrical dyssynchrony, we devised two novel ECG dyssynchrony criteria, which can estimate interventricular and left ventricular intraventricular dyssynchrony in order to improve patient selection for CRT. Here we discuss the results achieved by the application of these new ECG dyssynchrony criteria, which proved to be useful in predicting the CRT response in patients with nonspecific intraventricular conduction disturbance pattern (the second greatest group of CRT candidates), and the significance of other new ECG dyssynchrony criteria in the potential improvement of CRT outcome.
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10
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A different cardiac resynchronization therapy technique might be needed in some patients with nonspecific intraventricular conduction disturbance pattern. J Geriatr Cardiol 2021; 18:975-985. [PMID: 35136393 PMCID: PMC8782768 DOI: 10.11909/j.issn.1671-5411.2021.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Current cardiac resynchronization therapy (CRT), devised to eliminate dyssynchrony in left bundle branch block (LBBB), works by pacing the latest activated left ventricular site (LALVS). We hypothesized that patients with nonspecific intraventricular conduction disturbance (NICD) pattern respond less favorably to CRT, because their LALVS is far away from that in LBBB. METHODS By measuring the amplitude and polarity of secondary ST-segment alterations in two optional frontal and horizontal surface electrocardiogram (ECG) leads and using a software, we determined the resultant 3D spatial secondary ST vector, which is directed 180o away from the LALVS, in 110 patients with LBBB pattern and 77 patients with NICD pattern and heart failure. To validate the ECG method, we also estimated the LALVS by echocardiography using 3D parametric imaging and 2D speckle tracking in 22 LBBB patients and 20 NICD patients. Patients with NICD pattern were subdivided according to their non-overlapping frontal plane resultant secondary ST vector ranges to the NICD-1 subgroup (n = 44) and the NICD-2 subgroup (n = 33). RESULTS Based on the software determined coordinates of the resultant 3D spatial secondary ST vector directed 180o away from the LALVS, the LALVSs were located leftward, posterosuperior in the LBBB group, slightly left, superior in the NICD-1 subgroup, and slightly left, posteroinferior in the NICD-2 subgroup. The LALVS determined by ECG and echocardiography matched in all patients, except two. CONCLUSIONS In the NICD-2 subgroup, a remote LALVS was found from that in LBBB pattern, which might explain the high non-response rate of the NICD pattern to the current CRT technique.
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Fudim M, Dalgaard F, Fathallah M, Iskandrian AE, Borges-Neto S. Mechanical dyssynchrony: How do we measure it, what it means, and what we can do about it. J Nucl Cardiol 2021; 28:2174-2184. [PMID: 31144228 DOI: 10.1007/s12350-019-01758-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Accepted: 05/15/2019] [Indexed: 01/14/2023]
Abstract
Left ventricular mechanical dyssynchrony (LVMD) is defined by a difference in the timing of mechanical contraction or relaxation between different segments of the left ventricle (LV). Mechanical dyssynchrony is distinct from electrical dyssynchrony as measured by QRS duration and has been of increasing interest due to its association with worse prognosis and potential role in patient selection for cardiac resynchronization therapy (CRT). Although echocardiography is the most used modality to assess LVMD, some limitations apply to this modality. Compared to echo-based modalities, nuclear imaging by gated single-photon emission computed tomography (GSPECT) myocardial perfusion imaging (MPI) has clear advantages in evaluating systolic and diastolic LVMD. GSPECT MPI can determine systolic and diastolic mechanical dyssynchrony by the variability in the timing in which different LV segments contract or relax, which has prognostic impact in patients with coronary artery disease and heart failure. As such, by targeting mechanical dyssynchrony instead of electrical dyssynchrony, GSPECT MPI can potentially improve patient selection for CRT. So far, few studies have investigated the role of diastolic dyssynchrony, but recent evidence seems to suggest high prevalence and more prognostic impact than previously recognized. In the present review, we provide an oversight of mechanical dyssynchrony.
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Affiliation(s)
- Marat Fudim
- Duke University Medical Center, Duke University, 2301 Erwin Road, Durham, NC, 27710, USA.
- Duke Clinical Research Institute, Durham, NC, USA.
| | - Frederik Dalgaard
- Duke Clinical Research Institute, Durham, NC, USA
- Department of Cardiology, Herlev & Gentofte Hospital, Copenhagen, Denmark
| | | | - Ami E Iskandrian
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Salvator Borges-Neto
- Duke University Medical Center, Duke University, 2301 Erwin Road, Durham, NC, 27710, USA
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12
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Sillanmäki S, Gimelli A, Ahmad S, Samir S, Laitinen T, Soman P. Mechanisms of left ventricular dyssynchrony: A multinational SPECT study of patients with bundle branch block. J Nucl Cardiol 2021; 28:1140-1150. [PMID: 32060855 DOI: 10.1007/s12350-020-02054-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2019] [Accepted: 01/16/2020] [Indexed: 10/25/2022]
Abstract
BACKGROUND To better understand the mechanisms of left ventricular (LV) mechanical dyssynchrony (LVMD), we explored the relative contributions of QRS duration (QRSd), LV ejection fraction (EF), volumes and scar to LVMD measured by gated single-photon emission tomography in a population of consecutive patients with left bundle branch block (LBBB) and right bundle branch block (RBBB) compared to controls. METHODS Myocardial perfusion imaging studies of 275 LBBB and 83 RBBB patients from three centers were analyzed. LVMD was defined as an abnormal phase bandwidth or phase standard deviation. Hospital and gender-specific normal values were obtained from 172 controls. RESULTS The prevalence of LVMD was 85 and 40% in LBBB and RBBB, respectively. Ejection fraction, scar severity, and LBBB morphology independently explained 70% of variance seen in PhaseBW. Ejection fraction had the highest area under the curve (AUC 0.918) in the receiver operating characteristics analysis of LVMD with an optimal cut-off of 47% (sensitivity 73% and specificity 98%). Notably, QRSd was not predictive. CONCLUSION LV mechanical dysfunction plays a greater role than conduction abnormality in the genesis of LVMD, a finding that is intriguing in the context of contemporary literature which suggests that QRSd is the parameter that is most predictive of CRT response.
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Affiliation(s)
- Saara Sillanmäki
- Institute of Clinical Medicine, University of Eastern Finland, Joensuu, Finland
- Department of Nuclear Medicine and Clinical Physiology, Kuopio University Hospital, PL 100, 70029 KYS, Kuopio, Finland
| | | | - Shahzad Ahmad
- Division of Cardiology and The Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Saba Samir
- Division of Cardiology and The Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Tomi Laitinen
- Institute of Clinical Medicine, University of Eastern Finland, Joensuu, Finland
- Department of Nuclear Medicine and Clinical Physiology, Kuopio University Hospital, PL 100, 70029 KYS, Kuopio, Finland
| | - Prem Soman
- Division of Cardiology and The Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
- University of Pittsburgh Medical Center, A429 Scaife Hall, 200 Lothrop Street, Pittsburgh, PA, 15213, USA.
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Mele D, Trevisan F, Fiorencis A, Smarrazzo V, Bertini M, Ferrari R. Current Role of Echocardiography in Cardiac Resynchronization Therapy: from Cardiac Mechanics to Flow Dynamics Analysis. Curr Heart Fail Rep 2021; 17:384-396. [PMID: 32979151 DOI: 10.1007/s11897-020-00484-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
PURPOSE OF REVIEW The aim of this review is to summarily explain what LV synchrony, coordination, myocardial work, and flow dynamics are, trying to clarify their advantages and limitations in the treatment of heart failure patients undergoing or with implanted cardiac resynchronization therapy (CRT). RECENT FINDINGS CRT is an established treatment for patients with heart failure and left ventricular systolic dysfunction. In the current guidelines, CRT implant indications rely only on electrical dyssynchrony, but in the last years, many aspects of cardiac mechanics (including contractile synchrony, coordination, propagation, and myocardial work) and flow dynamics have been studied using echocardiographic techniques to better characterize patients undergoing or with implanted CRT. However, the concepts, limits, and potential applications of all these echocardiographic evaluations are unclear to most clinicians. The use of left ventricular dyssynchrony and discoordination indices may help to identify those significant mechanical alterations whose correction may increase the probability of a favorable CRT response. Assessment of myocardial work and intracardiac flow dynamics may overcome some limitations of the conventional evaluation of cardiac mechanics but more investigations are needed before extensive clinical application.
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Affiliation(s)
- Donato Mele
- Cardiac Unit, Azienda Ospedaliero-Universitaria, Via Aldo Moro 8, 44124, Cona (Ferrara), Italy.
| | - Filippo Trevisan
- Cardiac Unit, Azienda Ospedaliero-Universitaria, Via Aldo Moro 8, 44124, Cona (Ferrara), Italy
| | - Andrea Fiorencis
- Cardiac Unit, Azienda Ospedaliero-Universitaria, Via Aldo Moro 8, 44124, Cona (Ferrara), Italy
| | - Vittorio Smarrazzo
- Cardiac Unit, Azienda Ospedaliero-Universitaria, Via Aldo Moro 8, 44124, Cona (Ferrara), Italy
| | - Matteo Bertini
- Cardiac Unit, Azienda Ospedaliero-Universitaria, Via Aldo Moro 8, 44124, Cona (Ferrara), Italy
| | - Roberto Ferrari
- Cardiac Unit, Azienda Ospedaliero-Universitaria, Via Aldo Moro 8, 44124, Cona (Ferrara), Italy
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14
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Spatial variance in the 12-lead ECG and mechanical dyssynchrony. J Interv Card Electrophysiol 2021; 62:479-485. [PMID: 34014454 DOI: 10.1007/s10840-021-00999-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Accepted: 04/15/2021] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Electrical transmission disorders have a deleterious effect on cardiac depolarization, resulting in a disorganized ventricular contraction that reduces global mechanical efficiency; this mechanical dyssynchrony can be corrected by cardiac resynchronization therapy. However, despite adjustments in the electrical criteria selection of QRS for the recognition of mechanical dyssynchrony, a significant proportion of patients do not currently respond to this therapy. PURPOSE To find if a new predictor of dyssynchrony, the electrocardiogram spatial variance, is a better marker of mechanical dyssynchrony than QRS duration. METHODS Forty-seven electrocardiograms and 47 strain (2D speckle tracking) echocardiograms were prospectively collected simultaneously in consecutive, non-selected patients; the left ventricular mechanical dispersion was measured in all the cases. The electrocardiographic analysis of variance was made with a digital superposition of the electrocardiographic leads and generates different indexes of variance of both QRS complex and repolarization phase. RESULTS ROC analysis probed that the best area under the curve (AUC) value correlated with left ventricular mechanical dispersion and was obtained combining several spatial variance markers (considering depolarization and repolarization spatial variance together; AUC = 0.97); the same analysis using the QRS duration versus mechanical dispersion showed a significantly lower AUC value (AUC = 0.64). CONCLUSION Spatial variance combining depolarization and repolarization markers is a superior predictor of left ventricular mechanical dispersion than QRS duration.
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Cardiac Resynchronization Defibrillator Therapy for Nonspecific Intraventricular Conduction Delay Versus Right Bundle Branch Block. J Am Coll Cardiol 2020; 73:3082-3099. [PMID: 31221257 DOI: 10.1016/j.jacc.2019.04.025] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2018] [Revised: 02/17/2019] [Accepted: 04/02/2019] [Indexed: 11/24/2022]
Abstract
BACKGROUND The benefits of cardiac resynchronization therapy (CRT) in patients with non-left bundle branch block (LBBB) conduction abnormality have not been fully explored. OBJECTIVES This study sought to evaluate clinical outcomes among Medicare-aged patients with nonspecific intraventricular conduction delay (NICD) versus right bundle branch block (RBBB) in patients eligible for implantation with a CRT with defibrillator (CRT-D). METHODS Using the National Cardiovascular Data Registry implantable cardioverter-defibrillator (ICD) registry data between 2010 and 2013, the authors compared outcomes in CRT-eligible patients implanted with CRT-D versus ICD-only therapy among patients with NICD and RBBB. Also, among all CRT-D-implanted patients, the authors compared outcomes in those with NICD versus RBBB. Survival curves and multivariable adjusted hazard ratios (HRs) were used to assess outcomes including hospitalization and death. RESULTS In 11,505 non-LBBB CRT-eligible patients, after multivariable adjustment, among patients with RBBB, CRT-D was not associated with better outcomes, compared with ICD alone, regardless of QRS duration. Among patients with NICD and a QRS ≥150 ms, CRT-D was associated with decreased mortality at 3 years compared with ICD alone (HR: 0.602; 95% confidence interval [CI]: 0.416 to 0.871; p = 0.0071). Among 5,954 CRT-D-implanted patients, after multivariable adjustment NICD compared with RBBB was associated with lower mortality at 3 years in those with a QRS duration of ≥150 ms (HR: 0.757; 95% CI: 0.625 to 0.917; p = 0.0044). CONCLUSIONS Among non-LBBB CRT-D-eligible patients, CRT-D implantation was associated with better outcomes compared with ICD alone specifically in NICD patients with a QRS duration of ≥150 ms. Careful patient selection should be considered for CRT-D implantation in patients with non-LBBB conduction.
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16
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Sillanmäki S, Aapro S, Lipponen JA, Tarvainen MP, Laitinen T, Hedman M, Hämäläinen H, Laitinen T. Electrical and mechanical dyssynchrony in patients with right bundle branch block. J Nucl Cardiol 2020; 27:621-630. [PMID: 30143955 DOI: 10.1007/s12350-018-1418-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Accepted: 08/13/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND Though fairly benign reputation, the right bundle branch block (RBBB) can cause left ventricular mechanical dyssynchrony (LVMD). Still, the relationship between electrical disturbance and LVMD is partly unclear among these patients. METHODS Thirty patients with RBBB and 60 matching controls were studied with vector electrocardiography and myocardial perfusion imaging phase analysis. RBBB group was divided into those with and those without LVMD. RESULTS Prevalence of LVMD among RBBB patients was 50% and among controls 22%. Odds ratio (OR) for LVMD in patients with RBBB vs controls without RBBB was 3.6 (95% CI 1.4 to 9.3). Ejection fraction (EF), end-systolic volume, the angle between QRS and T vectors, and the QRS angle in the sagittal plane were significantly different between RBBB patients with and without LVMD. The QRS duration was comparable in these groups. EF associated independently with LVMD, explaining 60% of its variation. A cut-off value of EF ≤ 55% detected LVMD in 100% specificity (sensitivity of 47%). CONCLUSION Half of the patients with RBBB had LVMD. The OR for LVMD between RBBB and normal ECG was 3.6. It seems that EF, rather than electrical parameters, is the main determinant of LVMD. This information might be useful when evaluating indications for cardiac resynchronization therapy.
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Affiliation(s)
- Saara Sillanmäki
- Department of Clinical Physiology and Nuclear Medicine, Kuopio University Hospital, PL 100, 70029, Kuopio, Finland.
- University of Eastern Finland, Kuopio, Finland.
| | - Sini Aapro
- University of Eastern Finland, Kuopio, Finland
| | - Jukka A Lipponen
- Department of Applied Physics, University of Eastern Finland, Kuopio, Finland
| | - Mika P Tarvainen
- Department of Clinical Physiology and Nuclear Medicine, Kuopio University Hospital, PL 100, 70029, Kuopio, Finland
- Department of Applied Physics, University of Eastern Finland, Kuopio, Finland
| | - Tiina Laitinen
- Department of Clinical Physiology and Nuclear Medicine, Kuopio University Hospital, PL 100, 70029, Kuopio, Finland
| | - Marja Hedman
- Department of Clinical Radiology, Kuopio University Hospital, Kuopio, Finland
| | | | - Tomi Laitinen
- Department of Clinical Physiology and Nuclear Medicine, Kuopio University Hospital, PL 100, 70029, Kuopio, Finland
- University of Eastern Finland, Kuopio, Finland
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Solodky A, Zafrir N. Electrical and mechanical dyssynchrony in patients with right bundle branch block. J Nucl Cardiol 2020; 27:631-633. [PMID: 30298370 DOI: 10.1007/s12350-018-1460-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Accepted: 09/18/2018] [Indexed: 10/28/2022]
Affiliation(s)
- Alejandro Solodky
- Department of Cardiology, Rabin Medical Center, Tel Aviv University, Petah Tikva, Israel
| | - Nili Zafrir
- Department of Cardiology, Rabin Medical Center, Tel Aviv University, Petah Tikva, Israel.
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Salden OA, Vernooy K, van Stipdonk AM, Cramer MJ, Prinzen FW, Meine M. Strategies to Improve Selection of Patients Without Typical Left Bundle Branch Block for Cardiac Resynchronization Therapy. JACC Clin Electrophysiol 2020; 6:129-142. [DOI: 10.1016/j.jacep.2019.11.018] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Revised: 11/14/2019] [Accepted: 11/18/2019] [Indexed: 10/25/2022]
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Henin M, Ragy H, Mannion J, David S, Refila B, Boles U. Indications of Cardiac Resynchronization in Non-Left Bundle Branch Block: Clinical Review of Available Evidence. Cardiol Res 2020; 11:1-8. [PMID: 32095190 PMCID: PMC7011924 DOI: 10.14740/cr989] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 12/16/2019] [Indexed: 12/28/2022] Open
Abstract
Cardiac resynchronization therapy (CRT) benefits have been firmly established in patients with heart failure and reduced left ventricular ejection fraction (HFrEF), who remain in New York Heart Association (NYHA) functional classes II and III, despite optimal medical therapy, and have a wide QRS complex. An important and consistent finding in published systematic reviews and in subgroup analyses is that the benefits of CRT are maximum for patients with a broader QRS durations, typically described as QRS duration > 150 ms, and for patients with a typical left bundle branch block (LBBB) QRS morphology. It remains uncertain whether patients with non-LBBB QRS complex morphology clearly benefit from CRT or only modestly respond.
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Affiliation(s)
- Maged Henin
- University Hospital Waterford, Waterford, Ireland
| | - Hany Ragy
- National Heart Institute, Cairo, Egypt
| | | | - Santhosh David
- Cardiology Department, Letterkenny University Hospital, Donegal, Ireland
| | - Beshoy Refila
- Cardiology Department, Heart and Vascular Center, Mater Private Hospital, Dublin 7, Ireland
| | - Usama Boles
- Cardiology Department, Heart and Vascular Center, Mater Private Hospital, Dublin 7, Ireland
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Zeng D, Wu J, Wu SS, Lin HH, Chen H. Three-dimensional echocardiographic comparison of left ventricular geometry and systolic function between dilated cardiomyopathy and mitral regurgitation with similar left ventricular dilation. JOURNAL OF CLINICAL ULTRASOUND : JCU 2020; 48:29-37. [PMID: 31566758 DOI: 10.1002/jcu.22775] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Revised: 07/25/2019] [Accepted: 08/27/2019] [Indexed: 06/10/2023]
Abstract
PURPOSE This study aimed to analyze left ventricular (LV) remodeling in patients with LV dilation using three-dimensional (3D) echocardiography, and to compare geometry and systolic function between patients with dilated cardiomyopathy (DCM) and with mitral regurgitation (MR) but similar LV dimension. METHODS Cross-sectional study of 60 DCM and 60 MR patients with LV end diastolic diameter (LVEDD) > 35 mm/m2 , and of 60 healthy control volunteers. RESULTS Despite a similar LVEDD, DCM patients showed a significantly higher 3D sphericity index (3D-SI) than MR patients, whereas 3D ejection fraction (3D-EF) was significantly lower (P < .01). There was a linear relationship between 3D-EF and 3D-SI in both DCM and MR patients (r = -0. 745 and r = -0. 642, respectively; both P < .001). Receiver operating characteristic (ROC) curves showed that 3D-SI had could better discriminate between DCM and MR (sensitivity 90%; specificity 73%; AUC 0.852, P < .01) than other variables. The area under the ROC curve of 3D-SI was significantly larger than that of 3D-EF for detecting heart failure in both patients with DCM and MR. CONCLUSIONS LV geometry appears to be more spherical and associated with worse systolic function in DCM than in MR patients, in spite of similar LV dimensions. Systolic function correlated significantly with 3D-SI, which provided a better description of LV remodeling and could be a stronger indicator of heart failure in patients with LV dilation.
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Affiliation(s)
- DeCai Zeng
- Department of Ultrasonic Medicine, First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Ji Wu
- Department of Ultrasonic Medicine, First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Shui-Shun Wu
- Department of Ultrasonic Medicine, First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Hai-Hong Lin
- Department of Ultrasonic Medicine, First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Hui Chen
- Department of Ultrasonic Medicine, First Affiliated Hospital of Guangxi Medical University, Nanning, China
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Fudim M, Borges-Neto S. A troubled marriage: When electrical and mechanical dyssynchrony don't go along. J Nucl Cardiol 2019; 26:1240-1242. [PMID: 29450822 DOI: 10.1007/s12350-018-1227-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Accepted: 02/01/2018] [Indexed: 01/14/2023]
Affiliation(s)
- Marat Fudim
- Duke Department of Medicine and Division of Cardiology, Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
| | - Salvador Borges-Neto
- Duke Department of Radiology and Division of Nuclear Medicine, 2301 Erwin Road, Durham, NC, 27710, USA.
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Hernandez N, Huang DT. Updated Clinical Evidence for Effective Cardiac Resynchronization Therapy in Congestive Heart Failure and Timing of Implant. Card Electrophysiol Clin 2019; 11:55-65. [PMID: 30717853 DOI: 10.1016/j.ccep.2018.11.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Investigative works of the past 20 years have compiled extensive data on the effectiveness and implications of cardiac resynchronization therapy (CRT) in patients with heart failure. Since then, CRT has become a well-accepted and widely adapted adjunctive therapy for patients with heart failure with ventricular dyssynchrony. This overview discusses the updated knowledge on the benefits afforded with CRT and reviews the major clinical trials that have established CRT at its current practice. Based on the data, the indications of CRT and the timing of appropriate implant of CRT devices with respect to heart failure status will be presented.
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Affiliation(s)
- Natalia Hernandez
- Department of Cardiology, University of Rochester Medical Center, 601 Elmwood Avenue, Rochester, NY 14642, USA
| | - David T Huang
- Department of Cardiology, University of Rochester Medical Center, 601 Elmwood Avenue, Rochester, NY 14642, USA.
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Bonomini MP, Ortega DF, Barja LD, Mangani N, Arini PD. Depolarization spatial variance as a cardiac dyssynchrony descriptor. Biomed Signal Process Control 2019. [DOI: 10.1016/j.bspc.2018.12.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Kuznetsov VA, Soldatova AM, Kasprzak JD, Krinochkin DV, Melnikov NN. Echocardiographic markers of dyssynchrony as predictors of super-response to cardiac resynchronisation therapy - a pilot study. Cardiovasc Ultrasound 2018; 16:24. [PMID: 30285762 PMCID: PMC6167795 DOI: 10.1186/s12947-018-0140-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Accepted: 08/21/2018] [Indexed: 01/05/2023] Open
Abstract
Background Some patients with congestive heart failure have greater improvement of cardiac remodelling after cardiac resynchronisation therapy (CRT) and they are identified as super-responders (SRs). It remains unclear if echocardiographic markers of dyssynchrony could accuratelly predict super-response to CRT. The aim of this study is to evaluate potential echocardiographic predictors associated with super-response to CRT. Methods Fifthy nine CRT patients (mean age 52.9 ± 9.0 years, 88% men) with congestive heart failure (54% ischaemic and 46% non-ischaemic aetiology) II-IV NYHA functional class were enrolled. To assess mechanical dyssynchrony we evaluated interventricular mechanical delay, the maximum delay between peak systolic velocities of the septal and posterior walls of left ventricle, duration of left ventricular pre-ejection period (LVPEP), left ventricular and interventricular dyssynchrony by tissue Doppler imaging and systolic dyssynchrony index by 3D echocardiography. After six months the patients were assessed for response and classified as SRs (reduction in left ventricular end-systolic volume (LVESV) ≥30%, n = 20) and non-SRs (reduction in LVESV < 30%, n = 39) and baseline data were analyzed to identify the predictors. Results Both groups demonstrated significant improvement in NYHA functional class, increase in left ventricular ejection fraction and reduction in LVESV. All parameters of mechanical dyssynchrony at baseline were significantly higher in SR group. Multiple logistic regression analysis showed that LVPEP (HR 1.031; 95% CI 1.007–1.055; p = 0.011) was an independent predictor for CRT super-response. In ROC curve analysis LVPEP with a cut-off value of 147 ms demonstrated 73.7% sensitivity and 75% specificity (AUC = 0.753; p = 0.002) for the prediction of super-response to CRT. Conclusion Greater mechanical dyssynchrony is associated with super-response to CRT in patients with congestive heart failure. It is probable that an LVPEP > 147 ms can be used as independent predictor of super-response.
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Affiliation(s)
- V A Kuznetsov
- Tyumen Cardiology Research Center, Tomsk National Research Medical Center, Russian Academy of Science, Tomsk, Russia, Melnikaite st. 111, Tyumen, 625026, Russia
| | - A M Soldatova
- Tyumen Cardiology Research Center, Tomsk National Research Medical Center, Russian Academy of Science, Tomsk, Russia, Melnikaite st. 111, Tyumen, 625026, Russia.
| | - J D Kasprzak
- Department of Cardiology, Medical University of Lodz, Bieganski Hospital, Kniaziewicza 1/5, 91-347, Lodz, Poland
| | - D V Krinochkin
- Tyumen Cardiology Research Center, Tomsk National Research Medical Center, Russian Academy of Science, Tomsk, Russia, Melnikaite st. 111, Tyumen, 625026, Russia
| | - N N Melnikov
- Tyumen Cardiology Research Center, Tomsk National Research Medical Center, Russian Academy of Science, Tomsk, Russia, Melnikaite st. 111, Tyumen, 625026, Russia
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Hernandez GA, Blumer V, Arcay L, Monge J, Viles-Gonzalez JF, Lindenfeld J, Goldberger JJ, Chaparro S. Cardiac Resynchronization Therapy in Inotrope-Dependent Heart Failure Patients. JACC-HEART FAILURE 2018; 6:734-742. [DOI: 10.1016/j.jchf.2018.02.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Revised: 02/20/2018] [Accepted: 02/27/2018] [Indexed: 12/30/2022]
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Bonomini MP, Ortega DF, Barja LD, Logarzo E, Mangani N, Paolucci A. ECG parameters to predict left ventricular electrical delay. J Electrocardiol 2018; 51:844-850. [DOI: 10.1016/j.jelectrocard.2018.06.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Revised: 05/30/2018] [Accepted: 06/20/2018] [Indexed: 10/28/2022]
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Jeffrey RR, Hamburger RF, Gooden-Ebanks J, Petersen JW. Speckle Tracking Echocardiography Identifies Impaired Longitudinal Strain as a Common Deficit in Various Cardiac Diseases. CARDIOVASCULAR INNOVATIONS AND APPLICATIONS 2018. [DOI: 10.15212/cvia.2017.0040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Oka T, Inoue K, Tanaka K, Hirao Y, Isshiki T, Kimura T, Nobuyoshi M, Shizuta S, Arita T, Fujii S, Iwakura K, Fujii K, Ando K. Effect of QRS Morphology and Duration on Clinical Outcomes After Cardiac Resynchronization Therapy ― Analysis of Japanese Multicenter Registry ―. Circ J 2018; 82:1813-1821. [DOI: 10.1253/circj.cj-17-1383] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Takafumi Oka
- Cardiovascular Center, Sakurabashi Watanabe Hospital
| | - Koichi Inoue
- Cardiovascular Center, Sakurabashi Watanabe Hospital
| | - Koji Tanaka
- Cardiovascular Center, Sakurabashi Watanabe Hospital
| | - Yuko Hirao
- Cardiovascular Center, Sakurabashi Watanabe Hospital
| | | | - Takeshi Kimura
- Department of Cardiology, Kyoto University Graduate School of Medicine
| | | | - Satoshi Shizuta
- Department of Cardiology, Kyoto University Graduate School of Medicine
| | | | - Satoki Fujii
- Cardiology Department, Kurashiki Central Hospital
| | | | - Kenshi Fujii
- Cardiovascular Center, Sakurabashi Watanabe Hospital
| | - Kenji Ando
- Cardiovascular Division, Kokura Memorial Hospital
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Nguyên UC, Verzaal NJ, van Nieuwenhoven FA, Vernooy K, Prinzen FW. Pathobiology of cardiac dyssynchrony and resynchronization therapy. Europace 2018; 20:1898-1909. [DOI: 10.1093/europace/euy035] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2018] [Accepted: 02/16/2018] [Indexed: 02/04/2023] Open
Affiliation(s)
- Uyên Châu Nguyên
- Department of Physiology, Cardiovascular Research Institute Maastricht, Universiteitssingel 50, ER Maastricht, The Netherlands
- Department of Cardiology, Cardiovascular Research Institute Maastricht, Universiteitssingel 50, ER Maastricht, The Netherlands
| | - Nienke J Verzaal
- Department of Physiology, Cardiovascular Research Institute Maastricht, Universiteitssingel 50, ER Maastricht, The Netherlands
| | - Frans A van Nieuwenhoven
- Department of Physiology, Cardiovascular Research Institute Maastricht, Universiteitssingel 50, ER Maastricht, The Netherlands
| | - Kevin Vernooy
- Department of Cardiology, Cardiovascular Research Institute Maastricht, Universiteitssingel 50, ER Maastricht, The Netherlands
| | - Frits W Prinzen
- Department of Physiology, Cardiovascular Research Institute Maastricht, Universiteitssingel 50, ER Maastricht, The Netherlands
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Mechanical dyssynchrony in patients with heart failure and reduced ejection fraction: how to measure? Curr Opin Cardiol 2018; 31:523-30. [PMID: 27322767 DOI: 10.1097/hco.0000000000000314] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
PURPOSE OF REVIEW This article summarizes the most recent imaging techniques to assess left ventricular mechanical dyssynchrony and discusses their value to predict response to cardiac resynchronization therapy (CRT) together with assessment of myocardial scar and cardiac venous anatomy. RECENT FINDINGS Left ventricular mechanical dyssynchrony has been associated with prognosis of heart failure patients and has been shown to influence the efficacy of CRT. Although current guidelines do not recommend the assessment of left ventricular mechanical dyssynchrony to select heart failure patients for CRT, technological advances in echocardiography, cardiac magnetic resonance, nuclear imaging and computed tomography have provided powerful tools to characterize left ventricular mechanical dyssynchrony and predict response to CRT. Most important, these imaging techniques permit integration of additional information that is relevant for the efficacy of CRT, such as the extent and location of myocardial scar and the anatomy of the coronary sinus and tributaries where the left ventricular pacing lead may be positioned. SUMMARY Left ventricular mechanical dyssynchrony is an important parameter to select heart failure patients who are candidates for CRT. The integration of this parameter together with extent and location of myocardial scar and cardiac venous anatomy is a key to optimize the efficacy of CRT.
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Vereckei A, Szelényi Z, Kutyifa V, Zima E, Szénási G, Kiss M, Katona G, Karádi I, Merkely B. Novel electrocardiographic dyssynchrony criteria improve patient selection for cardiac resynchronization therapy. Europace 2018; 20:97-103. [PMID: 28011802 DOI: 10.1093/europace/euw326] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Accepted: 09/19/2016] [Indexed: 11/12/2022] Open
Abstract
Aims We hypothesized that the greater the intra- or interventricular dyssynchrony (intraD, interD), the more effective cardiac resynchronization therapy (CRT) is. We sought to improve patient selection for CRT by using novel ECG dyssynchrony criteria. Methods and results Left ventricular (LV) intraD was estimated by the absolute time difference between the intrinsicoid deflections (ID) in leads aVL and aVF divided by the QRS duration (QRSd): [aVLID - aVFID]/QRSd (%). InterD was estimated from the formula: [V5ID - V1ID]/QRSd (%). Their >25% value indicated electrical dyssynchrony present (ED+) and ≤25% value electrical dyssynchrony absent (ED-) diagnoses. Using the intraD + interD criteria (intra + interDC) together, if at least one of them indicated ED+ diagnosis, a final ED+ diagnosis, if both indicated ED- diagnosis, a final ED- diagnosis was made. Two authors, blinded to CRT response, retrospectively analysed pre-CRT ECGs of 124 patients with known CRT outcome. CRT response was defined as improvement of ≥ 1 NYHA class, being alive and having no hospitalizations for heart failure during 6 months of follow-up. 35/124 (28%) patients were non-responders (NRs), using the traditional criteria (TC) correct diagnosis was made in the remaining 89/124 (72%) responder (R) cases. The test accuracy (TA) of intra + interDC + TC [100/124 (81%), P < 0.001] was superior to that of TC [89/124 (72%)] due to its superior TA [36/43 (84%) vs. 29/43 (67%), respectively, P = 0.0156] in the non-specific intra-ventricular conduction disturbance (NICD) subgroup [43/124 (35%)]. In the left bundle branch block subgroup [70/124 (56%)] there was no between-criteria difference in TA. Conclusion The intra + interDC + TC predicts clinical response after CRT more accurately than TC alone, due to greater TA in the NICD subgroup.
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Affiliation(s)
- András Vereckei
- 3rd Department of Medicine, Semmelweis University, Kútvölgyi út 4, Budapest, Hungary 1125
| | - Zsuzsanna Szelényi
- Heart and Vascular Center, Semmelweis University, Városmajor u. 68, Budapest, Hungary 1122
| | - Valentina Kutyifa
- University of Rochester Medical Center, Cardiology Division, Heart Research Follow-up Program, 265 Crittenden Blvd, Box 653, Rochester NY, 14642, USA
| | - Endre Zima
- Heart and Vascular Center, Semmelweis University, Városmajor u. 68, Budapest, Hungary 1122
| | - Gábor Szénási
- Institute of Pathophysiology, Semmelweis University, Nagyvárad tér 4, Budapest, Hungary, 1089
| | - Melinda Kiss
- 3rd Department of Medicine, Semmelweis University, Kútvölgyi út 4, Budapest, Hungary 1125
| | - Gábor Katona
- 3rd Department of Medicine, Semmelweis University, Kútvölgyi út 4, Budapest, Hungary 1125
| | - István Karádi
- 3rd Department of Medicine, Semmelweis University, Kútvölgyi út 4, Budapest, Hungary 1125
| | - Béla Merkely
- Heart and Vascular Center, Semmelweis University, Városmajor u. 68, Budapest, Hungary 1122
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Chousou PA, Pugh PJ. How to deliver optimal cardiac resynchronisation therapy. Heart 2017; 104:1300-1307. [PMID: 29217631 DOI: 10.1136/heartjnl-2017-311210] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Revised: 08/24/2017] [Accepted: 11/02/2017] [Indexed: 01/06/2023] Open
Affiliation(s)
- Panagiota Anna Chousou
- Department of Cardiology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Peter J Pugh
- Department of Cardiology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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Atwater BD, Wagner GS, Kisslo J, Risum N. The electromechanical substrate for response to cardiac resynchronization therapy in patients with right bundle branch block. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2017; 40:1358-1367. [PMID: 29086988 DOI: 10.1111/pace.13231] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/02/2017] [Revised: 10/08/2017] [Accepted: 10/10/2017] [Indexed: 11/28/2022]
Abstract
BACKGROUND Some patients with RBBB may respond to cardiac resynchronization therapy (CRT). However, little is known regarding the electromechanical substrate for CRT and whether this is the optimal pacing strategy. METHODS This was a pilot prospective double crossover randomized controlled clinical study comparing ventricular back up pacing (VVI-40), RV fusion pacing (DDD-40, RV only), and biventricular (BIV) pacing (DDD-40 BIV) in nine patients with RBBB and depressed EF. The study compared the frequency of dyssynchrony on baseline echocardiogram in patients with RBBB (n = 4), RBBB + anterior MI (RBBB with left axis deviation + left ventricular (LV) anterior wall thinning, n = 3), and RBBB + LAFB (RBBB with left axis deviation without LV anterior wall thinning n = 2). Echocardiographic assessment of LV dyssynchrony, LV size, and LV function was repeated after 6 months in each pacing mode. RESULTS Patients with RBBB + LAFB demonstrated baseline echocardiographic dyssynchrony between the LV anterior and inferior wall. Both DDD-40 RV-only pacing and DDD-40 BIV pacing resulted in improved LV function and clinical status compared to VVI-40 back up pacing. Patients with RBBB alone and RBBB with anterior MI had no baseline dyssynchrony and CRT using either RV only or BIV pacing resulted in LV dilation, worsened left ventricular ejection fraction and worsened clinical status compared to VVI-40 back up pacing. CONCLUSION Patients with RBBB, left axis deviation, and no prior anterior MI may have LV dyssynchrony between the anterior and inferior walls that is correctable with CRT.
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Affiliation(s)
- Brett D Atwater
- Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Galen S Wagner
- Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Joseph Kisslo
- Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Niels Risum
- Department of Cardiology, Copenhagen University Hospital, Copenhagen, Denmark
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34
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Auricchio A, Prinzen FW. Enhancing Response in the Cardiac Resynchronization Therapy Patient. JACC Clin Electrophysiol 2017; 3:1203-1219. [DOI: 10.1016/j.jacep.2017.08.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Revised: 08/02/2017] [Accepted: 08/10/2017] [Indexed: 12/17/2022]
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Belkin MN, Upadhyay GA. Does Cardiac Resynchronization Therapy Benefit Patients with Non-Left Bundle Branch Block Prolonged QRS Patterns? Curr Cardiol Rep 2017; 19:125. [DOI: 10.1007/s11886-017-0929-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Hattori Y, Ishibashi K, Noda T, Okamura H, Kanzaki H, Anzai T, Yasuda S, Kusano K. Earlier Right Ventricular Pacing in Cardiac Resynchronization Therapy for a Patient with Right Axis Deviation. Intern Med 2017; 56:2285-2288. [PMID: 28794367 PMCID: PMC5635300 DOI: 10.2169/internalmedicine.8458-16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
We describe the case of a 37-year-old woman who presented with complete right bundle branch block and right axis deviation. She was admitted to our hospital due to severe heart failure and was dependent on inotropic agents. Cardiac resynchronization therapy was initiated but did not improve her condition. After the optimization of the pacing timing, we performed earlier right ventricular pacing, which led to an improvement of her heart failure. Earlier right ventricular pacing should be considered in patients with complete right bundle branch block and right axis deviation when cardiac resynchronization therapy is not effective.
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Affiliation(s)
- Yusuke Hattori
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Japan
| | - Kohei Ishibashi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Japan
- Department of Cardiovascular Medicine, Wakayama Medical University, Japan
| | - Takashi Noda
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Japan
| | - Hideo Okamura
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Japan
| | - Hideaki Kanzaki
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Japan
| | - Toshihisa Anzai
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Japan
| | - Satoshi Yasuda
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Japan
| | - Kengo Kusano
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Japan
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PR interval prolongation in coronary patients or risk equivalent: excess risk of ischemic stroke and vascular pathophysiological insights. BMC Cardiovasc Disord 2017; 17:233. [PMID: 28836952 PMCID: PMC5571504 DOI: 10.1186/s12872-017-0667-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2017] [Accepted: 08/17/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Whether PR prolongation independently predicts new-onset ischemic events of myocardial infarction and stroke was unclear. Underlying pathophysiological mechanisms of PR prolongation leading to adverse cardiovascular events were poorly understood. We investigated the role of PR prolongation in pathophysiologically-related adverse cardiovascular events and underlying mechanisms. METHODS We prospectively investigated 597 high-risk cardiovascular outpatients (mean age 66 ± 11 yrs.; male 67%; coronary disease 55%, stroke 22%, diabetes 52%) for new-onset ischemic stroke, myocardial infarction (MI), congestive heart failure (CHF), and cardiovascular death. Vascular phenotype was determined by carotid intima-media thickness (IMT). RESULTS PR prolongation >200 ms was present in 79 patients (13%) at baseline. PR prolongation >200 ms was associated with significantly higher mean carotid IMT (1.05 ± 0.37 mm vs 0.94 ± 0.28 mm, P = 0.010). After mean study period of 63 ± 11 months, increased PR interval significantly predicted new-onset ischemic stroke (P = 0.006), CHF (P = 0.040), cardiovascular death (P < 0.001), and combined cardiovascular endpoints (P < 0.001) at cut-off >200 ms. Using multivariable Cox regression, PR prolongation >200 ms independently predicted new-onset ischemic stroke (HR 8.6, 95% CI: 1.9-37.8, P = 0.005), cardiovascular death (HR 14.1, 95% CI: 3.8-51.4, P < 0.001) and combined cardiovascular endpoints (HR 2.4, 95% CI: 1.30-4.43, P = 0.005). PR interval predicts new-onset MI at the exploratory cut-off >162 ms (C-statistic 0.70, P = 0.001; HR: 8.0, 95% CI: 1.65-38.85, P = 0.010). CONCLUSIONS PR prolongation strongly predicts new-onset ischemic stroke, MI, cardiovascular death, and combined cardiovascular endpoint including CHF in coronary patients or risk equivalent. Adverse vascular function may implicate an intermediate pathophysiological phenotype or mediating mechanism.
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Madhavan M, Mulpuru SK, McLeod CJ, Cha YM, Friedman PA. Advances and Future Directions in Cardiac Pacemakers: Part 2 of a 2-Part Series. J Am Coll Cardiol 2017; 69:211-235. [PMID: 28081830 DOI: 10.1016/j.jacc.2016.10.064] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2016] [Revised: 10/17/2016] [Accepted: 10/26/2016] [Indexed: 10/20/2022]
Abstract
In the second part of this 2-part series on pacemakers, we present recent advances in pacemakers and preview future developments. Cardiac resynchronization therapy (CRT) is a potent treatment for heart failure in the setting of ventricular dyssynchrony. Successful CRT using coronary venous pacing depends on appropriate patient selection, lead implantation, and device programming. Despite optimization of these factors, nonresponse to CRT may occur in one-third of patients, which has led to a search for alternative techniques such as multisite pacing, His bundle pacing, and endocardial left ventricular pacing. A paradigm shift in pacemaker technology has been the development of leadless pacemaker devices, and on the horizon is the development of batteryless devices. Remote monitoring has ushered in an era of greater safety and the ability to respond to device malfunction in a timely fashion, improving outcomes.
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Affiliation(s)
- Malini Madhavan
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - Siva K Mulpuru
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | | | - Yong-Mei Cha
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - Paul A Friedman
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota.
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Abstract
Echocardiographic imaging plays a major role in patient selection for cardiac resynchronization therapy (CRT). One-third of patients do not respond; there is interest in advanced echocardiographic imaging to improve response. Current guidelines favor CRT for patients with electrocardiographic (ECG) QRS width of 150 milliseconds or greater and left bundle branch block. ECG criteria are imperfect; there is interest in advanced echocardiographic imaging to improve patient selection. This discussion focuses on newer echocardiographic methods to improve patient selection, improve delivery, and identify patients at risk for poor outcomes and serious ventricular arrhythmias.
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Affiliation(s)
- John Gorcsan
- Heart and Vascular Institute, Division of Cardiology, University of Pittsburgh, Pittsburgh, PA, USA.
| | - Bhupendar Tayal
- Heart and Vascular Institute, Division of Cardiology, University of Pittsburgh, Pittsburgh, PA, USA
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40
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Marechaux S, Menet A, Guyomar Y, Ennezat PV, Guerbaai RA, Graux P, Tribouilloy C. Role of echocardiography before cardiac resynchronization therapy: new advances and current developments. Echocardiography 2016; 33:1745-1752. [DOI: 10.1111/echo.13334] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Affiliation(s)
- Sylvestre Marechaux
- Lille North of France University/Catholic University Hospital/Catholic School of Medicine; Cardiology Department; Lille Catholic University; Lille France
- INSERM U 1088; University of Picardie; Amiens France
| | - Aymeric Menet
- Lille North of France University/Catholic University Hospital/Catholic School of Medicine; Cardiology Department; Lille Catholic University; Lille France
- INSERM U 1088; University of Picardie; Amiens France
| | - Yves Guyomar
- Lille North of France University/Catholic University Hospital/Catholic School of Medicine; Cardiology Department; Lille Catholic University; Lille France
| | | | - Raphaëlle Ashley Guerbaai
- Cardiology Department; Grenoble University Hospital; Grenoble France
- Cardiovascular and Thoracic Department; Amiens University Hospital; Amiens France
| | - Pierre Graux
- Lille North of France University/Catholic University Hospital/Catholic School of Medicine; Cardiology Department; Lille Catholic University; Lille France
| | - Christophe Tribouilloy
- INSERM U 1088; University of Picardie; Amiens France
- Cardiovascular and Thoracic Department; Amiens University Hospital; Amiens France
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Bilateral bundle branch block, an old concept revisited in the light of cardiac resynchronization therapy. Heart Rhythm 2016; 13:2297-2298. [PMID: 27544745 DOI: 10.1016/j.hrthm.2016.08.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Indexed: 11/23/2022]
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42
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Leeters IPM, Davis A, Zusterzeel R, Atwater B, Risum N, Søgaard P, Klem I, Nijveldt R, Wagner GS, Gorgels APM, Kisslo J. Left ventricular regional contraction abnormalities by echocardiographic speckle tracking in combined right bundle branch with left anterior fascicular block compared to left bundle branch block. J Electrocardiol 2016; 49:353-61. [PMID: 26931516 DOI: 10.1016/j.jelectrocard.2016.02.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND In contrast to LBBB patients less is known about patients with RBBB+LAFB regarding LV contractile abnormalities and the potential role of CRT. This study investigated whether patients with RBBB+LAFB morphology have echocardiographic mechanical strain abnormalities between the inferior and anterior LV walls, similar to abnormalities between septal and lateral walls in LBBB. METHODS AND RESULTS Ten healthy volunteers with no-BBB, 28 LBBB and 28 RBBB+LAFB heart failure patients were included in this retrospective study. Two-dimensional regional-strains were obtained by speckle-tracking. Scar was assessed by CMR. Response on echo was defined as normal, classical, borderline or other pattern. The number of classical patterns in LBBB was significantly higher than in RBBB+LAFB and no-BBB groups (p<0.001 for both). Contrary, the RBBB+LAFB group showed a significantly higher number of borderline patterns compared to other groups (LBBB: p=0.042, no-block: p=0.012). In addition, RBBB+LAFB patients had more scar than LBBB patients (9.9% vs 3.4%, p=0.041), and the average amount of scar in each wall was also higher in RBBB+LAFB (<5% in LBBB and <16% in RBBB+LAFB). CONCLUSIONS Patients with RBBB+LAFB on ECG and clinical HF demonstrate echocardiographic wall motion abnormalities between inferior and anterior LV walls, similar to abnormalities found between septal and lateral LV walls in patients with LBBB and HF. Fewer patients with RBBB+LAFB showed a classical pattern of opposing wall motion compared to LBBB. Factors that might alter strain patterns in RBBB+LAFB, including the detailed presence or absence of LV scar and coexisting block of the central fascicle, should be assessed in future studies.
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Affiliation(s)
- Irene P M Leeters
- Department of Cardiology, Maastricht University Medical Center, Maastricht, The Netherlands.
| | - Ashlee Davis
- Department of Cardiology, Duke University Medical Center, Durham, NC, USA
| | | | - Brett Atwater
- Department of Cardiology, Duke University Medical Center, Durham, NC, USA
| | - Niels Risum
- Department of Cardiology, Copenhagen University Hospital, Copenhagen, Denmark
| | - Peter Søgaard
- Heart Centre and Clinical Institute, Aalborg University Hospital, Aalborg, Denmark
| | - Igor Klem
- Department of Cardiology, Duke University Medical Center, Durham, NC, USA
| | - Robin Nijveldt
- Department of Cardiology, VU University Medical Center, Amsterdam, The Netherlands
| | - Galen S Wagner
- Department of Cardiology, Duke University Medical Center, Durham, NC, USA
| | - Anton P M Gorgels
- Department of Cardiology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Joseph Kisslo
- Department of Cardiology, Duke University Medical Center, Durham, NC, USA
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The role of electrocardiography in the elaboration of a new paradigm in cardiac resynchronization therapy for patients with nonspecific intraventricular conduction disturbance. J Geriatr Cardiol 2016; 13:118-25. [PMID: 27168736 PMCID: PMC4854949 DOI: 10.11909/j.issn.1671-5411.2016.02.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Cardiac resynchronization therapy (CRT) is associated with a favorable outcome only in patients with left bundle branch block (LBBB) pattern and in patients with a QRS duration > 150 ms, in patients with non-LBBB pattern with a QRS duration of 120–150 ms usually is not beneficial. After adjusting for QRS duration, QRS morphology was no longer a determinant of the clinical response to CRT. In contrast to the mainstream view, we hypothesized that the unfavorable CRT outcome in patients with non-LBBB and a QRS duration of 120–150 ms is not due to the QRS morphology itself, but to less dyssynchrony and unfavorable patient characteristics in this subgroup, such as more ischemic etiology and greater prevalence of male patients compared with patients with LBBB pattern. Further, the current CRT technique is devised to eliminate the dyssynchrony present in patients with LBBB pattern and inappropriate to eliminate the dyssynchrony in patients with non-LBBB pattern. We also hypothesized that electrocardiography may also provide information about the presence of interventricular and left intraventricular dyssynchrony and the approximate location of the latest activated left ventricular (LV) region. To this end, we devised new ECG criteria to estimate interventricular and LV intraventricular dyssynchrony and the approximate location of the latest activated LV region. Our preliminary data demonstrated that the latest activated LV region in patients with nonspecific intraventricular conduction disturbance (NICD) pattern might be at a remote site from that present in patients with LBBB pattern, which might necessitate the invention of a novel CRT technique for patients with NICD pattern. The application of the new interventricular and LV intraventricular dyssynchrony ECG criteria and a potential novel CRT technique might decrease the currently high nonresponder rate in patients with NICD pattern.
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Is speckle tracking actually helpful for cardiac resynchronization therapy? J Echocardiogr 2016; 14:53-60. [PMID: 26767529 DOI: 10.1007/s12574-016-0275-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2015] [Revised: 12/09/2015] [Accepted: 12/28/2015] [Indexed: 10/22/2022]
Abstract
What is the specific role of echocardiography in cardiac resynchronization therapy (CRT)? CRT has proven to be highly effective for improving symptoms and survival of patients with advanced heart failure (HF) and wide QRS. However, a significant minority of patients do not respond favorably to CRT on the basis of standard clinical selection criteria, including the electrocardiographic QRS width. Subsequently, echocardiographic assessment of left ventricular (LV) dyssynchrony has been considered useful for CRT for selected responders, but findings by multicenter studies suggest that its predictive value was not sufficiently robust to replace routine selection criteria for CRT. A more recent approach, however, using speckle-tracking echocardiography yields more accurate quantification of regional wall contraction. Speckle-tracking approaches have therefore generated a great deal of interest about their clinical applications for CRT. Although reports on speckle tracking have not been included in any recommendations as to whether patients should undergo CRT based on the current guidelines, speckle tracking can play an important supplementary part in CRT on the basis of a case-by-case clinical decision for challenging cases. Here, we review the strengths of speckle-tracking methods, and their current potential for clinical use in CRT.
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van Stipdonk AMW, Rad MM, Luermans JGLM, Crijns HJ, Prinzen FW, Vernooy K. Identifying delayed left ventricular lateral wall activation in patients with non-specific intraventricular conduction delay using coronary venous electroanatomical mapping. Neth Heart J 2015; 24:58-65. [PMID: 26635130 PMCID: PMC4692839 DOI: 10.1007/s12471-015-0777-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Background Delayed left ventricular (LV) lateral wall activation is considered the electrical substrate that characterises patients suitable for cardiac resynchronisation therapy (CRT). Although typically associated with left bundle branch block, delayed LV lateral wall activation may also be present in patients with non-specific intraventricular conduction delay (IVCD). We assessed LV lateral wall activation in a cohort of CRT candidates with IVCD using coronary venous electroanatomical mapping, and investigated whether baseline QRS characteristics on the ECG can identify delayed LV lateral wall activation in this group of patients. Methods Twenty-three consecutive CRT candidates with IVCD underwent intra-procedural coronary venous electroanatomical mapping using EnSite NavX. Electrical activation time was measured in milliseconds from QRS onset and expressed as percentage of QRS duration. LV lateral wall activation was considered delayed if maximal activation time measured at the LV lateral wall (LVLW-AT) exceeded 75 % of the QRS duration. QRS morphology, duration, fragmentation, axis deviation, and left anterior/posterior fascicular block were assessed on baseline ECGs. Results Delayed LV lateral wall activation occurred in 12/23 patients (maximal LVLW-AT = 133 ± 20 ms [83 ± 5 % of QRS duration]). In these patients, the latest activated region was consistently located on the basal lateral wall. QRS duration, and prevalence of QRS fragmentation and left/right axis deviation, and left anterior/posterior fascicular block did not differ between patients with and without delayed LV lateral wall activation. Conclusion Coronary venous electroanatomical mapping can be used at the time of CRT implantation to determine the presence of delayed LV lateral wall activation in patients with IVCD. QRS characteristics on the ECG seem unable to identify delayed LV lateral wall activation in this subgroup of patients.
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Affiliation(s)
- A M W van Stipdonk
- Department of Cardiology, Maastricht University Medical Center, PO Box 5800, 6202AZ, Maastricht, The Netherlands
| | - M Mafi Rad
- Department of Cardiology, Maastricht University Medical Center, PO Box 5800, 6202AZ, Maastricht, The Netherlands
| | - J G L M Luermans
- Department of Cardiology, Maastricht University Medical Center, PO Box 5800, 6202AZ, Maastricht, The Netherlands
| | - H J Crijns
- Department of Cardiology, Maastricht University Medical Center, PO Box 5800, 6202AZ, Maastricht, The Netherlands
| | - F W Prinzen
- Department of Physiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - K Vernooy
- Department of Cardiology, Maastricht University Medical Center, PO Box 5800, 6202AZ, Maastricht, The Netherlands.
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Gorcsan J, Tayal B. Newer Echocardiographic Techniques in Cardiac Resynchronization Therapy. Card Electrophysiol Clin 2015; 7:609-618. [PMID: 26596806 DOI: 10.1016/j.ccep.2015.08.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Echocardiographic imaging plays a major role in patient selection for cardiac resynchronization therapy (CRT). One-third of patients do not respond; there is interest in advanced echocardiographic imaging to improve response. Current guidelines favor CRT for patients with electrocardiographic (ECG) QRS width of 150 milliseconds or greater and left bundle branch block. ECG criteria are imperfect; there is interest in advanced echocardiographic imaging to improve patient selection. This discussion focuses on newer echocardiographic methods to improve patient selection, improve delivery, and identify patients at risk for poor outcomes and serious ventricular arrhythmias.
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Affiliation(s)
- John Gorcsan
- Heart and Vascular Institute, Division of Cardiology, University of Pittsburgh, Pittsburgh, PA, USA.
| | - Bhupendar Tayal
- Heart and Vascular Institute, Division of Cardiology, University of Pittsburgh, Pittsburgh, PA, USA
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Lumens J, Tayal B, Walmsley J, Delgado-Montero A, Huntjens PR, Schwartzman D, Althouse AD, Delhaas T, Prinzen FW, Gorcsan J. Differentiating Electromechanical From Non-Electrical Substrates of Mechanical Discoordination to Identify Responders to Cardiac Resynchronization Therapy. Circ Cardiovasc Imaging 2015; 8:e003744. [PMID: 26338877 DOI: 10.1161/circimaging.115.003744] [Citation(s) in RCA: 113] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Left ventricular (LV) mechanical discoordination, often referred to as dyssynchrony, is often observed in patients with heart failure regardless of QRS duration. We hypothesized that different myocardial substrates for LV mechanical discoordination exist from (1) electromechanical activation delay, (2) regional differences in contractility, or (3) regional scar and that we could differentiate electromechanical substrates responsive to cardiac resynchronization therapy (CRT) from unresponsive non-electrical substrates. METHODS AND RESULTS First, we used computer simulations to characterize mechanical discoordination patterns arising from electromechanical and non-electrical substrates and accordingly devise the novel systolic stretch index (SSI), as the sum of posterolateral systolic prestretch and septal systolic rebound stretch. Second, 191 patients with heart failure (QRS duration ≥120 ms; LV ejection fraction ≤35%) had baseline SSI quantified by automated echocardiographic radial strain analysis. Patients with SSI≥9.7% had significantly less heart failure hospitalizations or deaths 2 years after CRT (hazard ratio, 0.32; 95% confidence interval, 0.19-0.53; P<0.001) and less deaths, transplants, or LV assist devices (hazard ratio, 0.28; 95% confidence interval, 0.15-0.55; P<0.001). Furthermore, in a subgroup of 113 patients with intermediate electrocardiographic criteria (QRS duration of 120-149 ms or non-left bundle branch block), SSI≥9.7% was independently associated with significantly less heart failure hospitalizations or deaths (hazard ratio, 0.41; 95% confidence interval, 0.23-0.79; P=0.004) and less deaths, transplants, or LV assist devices (hazard ratio, 0.27; 95% confidence interval, 0.12-0.60; P=0.001). CONCLUSIONS Computer simulations differentiated patterns of LV mechanical discoordination caused by electromechanical substrates responsive to CRT from those related to regional hypocontractility or scar unresponsive to CRT. The novel SSI identified patients who benefited more favorably from CRT, including those with intermediate electrocardiographic criteria, where CRT response is less certain by ECG alone.
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Affiliation(s)
- Joost Lumens
- From the CARIM School for Cardiovascular Diseases, Maastricht University Medical Center, Maastricht, The Netherlands (J.L., J.W., P.R.H., T.D., F.W.P.); L'Institut de Rythmologie et Modélisation Cardiaque (IHU-LIRYC), Pessac-Bordeaux, France (J.L., P.R.H.); and Heart and Vascular Institute, University of Pittsburgh Medical Center, PA (B.T., A.D.-M., D.S., A.D.A., J.G.).
| | - Bhupendar Tayal
- From the CARIM School for Cardiovascular Diseases, Maastricht University Medical Center, Maastricht, The Netherlands (J.L., J.W., P.R.H., T.D., F.W.P.); L'Institut de Rythmologie et Modélisation Cardiaque (IHU-LIRYC), Pessac-Bordeaux, France (J.L., P.R.H.); and Heart and Vascular Institute, University of Pittsburgh Medical Center, PA (B.T., A.D.-M., D.S., A.D.A., J.G.)
| | - John Walmsley
- From the CARIM School for Cardiovascular Diseases, Maastricht University Medical Center, Maastricht, The Netherlands (J.L., J.W., P.R.H., T.D., F.W.P.); L'Institut de Rythmologie et Modélisation Cardiaque (IHU-LIRYC), Pessac-Bordeaux, France (J.L., P.R.H.); and Heart and Vascular Institute, University of Pittsburgh Medical Center, PA (B.T., A.D.-M., D.S., A.D.A., J.G.)
| | - Antonia Delgado-Montero
- From the CARIM School for Cardiovascular Diseases, Maastricht University Medical Center, Maastricht, The Netherlands (J.L., J.W., P.R.H., T.D., F.W.P.); L'Institut de Rythmologie et Modélisation Cardiaque (IHU-LIRYC), Pessac-Bordeaux, France (J.L., P.R.H.); and Heart and Vascular Institute, University of Pittsburgh Medical Center, PA (B.T., A.D.-M., D.S., A.D.A., J.G.)
| | - Peter R Huntjens
- From the CARIM School for Cardiovascular Diseases, Maastricht University Medical Center, Maastricht, The Netherlands (J.L., J.W., P.R.H., T.D., F.W.P.); L'Institut de Rythmologie et Modélisation Cardiaque (IHU-LIRYC), Pessac-Bordeaux, France (J.L., P.R.H.); and Heart and Vascular Institute, University of Pittsburgh Medical Center, PA (B.T., A.D.-M., D.S., A.D.A., J.G.)
| | - David Schwartzman
- From the CARIM School for Cardiovascular Diseases, Maastricht University Medical Center, Maastricht, The Netherlands (J.L., J.W., P.R.H., T.D., F.W.P.); L'Institut de Rythmologie et Modélisation Cardiaque (IHU-LIRYC), Pessac-Bordeaux, France (J.L., P.R.H.); and Heart and Vascular Institute, University of Pittsburgh Medical Center, PA (B.T., A.D.-M., D.S., A.D.A., J.G.)
| | - Andrew D Althouse
- From the CARIM School for Cardiovascular Diseases, Maastricht University Medical Center, Maastricht, The Netherlands (J.L., J.W., P.R.H., T.D., F.W.P.); L'Institut de Rythmologie et Modélisation Cardiaque (IHU-LIRYC), Pessac-Bordeaux, France (J.L., P.R.H.); and Heart and Vascular Institute, University of Pittsburgh Medical Center, PA (B.T., A.D.-M., D.S., A.D.A., J.G.)
| | - Tammo Delhaas
- From the CARIM School for Cardiovascular Diseases, Maastricht University Medical Center, Maastricht, The Netherlands (J.L., J.W., P.R.H., T.D., F.W.P.); L'Institut de Rythmologie et Modélisation Cardiaque (IHU-LIRYC), Pessac-Bordeaux, France (J.L., P.R.H.); and Heart and Vascular Institute, University of Pittsburgh Medical Center, PA (B.T., A.D.-M., D.S., A.D.A., J.G.)
| | - Frits W Prinzen
- From the CARIM School for Cardiovascular Diseases, Maastricht University Medical Center, Maastricht, The Netherlands (J.L., J.W., P.R.H., T.D., F.W.P.); L'Institut de Rythmologie et Modélisation Cardiaque (IHU-LIRYC), Pessac-Bordeaux, France (J.L., P.R.H.); and Heart and Vascular Institute, University of Pittsburgh Medical Center, PA (B.T., A.D.-M., D.S., A.D.A., J.G.)
| | - John Gorcsan
- From the CARIM School for Cardiovascular Diseases, Maastricht University Medical Center, Maastricht, The Netherlands (J.L., J.W., P.R.H., T.D., F.W.P.); L'Institut de Rythmologie et Modélisation Cardiaque (IHU-LIRYC), Pessac-Bordeaux, France (J.L., P.R.H.); and Heart and Vascular Institute, University of Pittsburgh Medical Center, PA (B.T., A.D.-M., D.S., A.D.A., J.G.)
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Zhang J, Xing Q, Zhou X, Zhang Y, Li Y, Li J, Tang B. Effects of Cardiac Resynchronization Therapy on Ventricular Electrical Remodeling in Patients With Heart Failure. Int Heart J 2015; 56:495-9. [PMID: 26370368 DOI: 10.1536/ihj.15-104] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Cardiac resynchronization therapy (CRT) reverses structural remodeling of the left ventricle. We investigated whether CRT reverses left-ventricular electrical remodeling.Eighty patients were enrolled and implanted with CRT-devices. Echocardiography and electrocardiography data were obtained from each patient prior to implantation and two years after implantation. At two years after implantation, the patients were classified into a responder group and a non-responder group based on echocardiography.Over the next 2 years, 75 patients completed follow-up, and 5 patients had died. Echocardiography results showed that 23 patients could be classified as non-responders and 52 as responders. Larger numbers of non-responders were diagnosed with either ischemic cardiomyopathy (ICM) or nonspecific intraventricular conduction delay (NICD). The intrinsic QRS duration was not changed in responders, patients with dilated cardiomyopathy, or in the patient categories of male and female. However, the intrinsic QRS duration was significantly prolonged in non-responders and patients with ischemic cardiomyopathy (P = 0.041). The mean left ventricular end-diastolic diameter in the responder group was significantly decreased by CRT (P < 0.05), while there was no significant change in intrinsic QRS duration.While CRT does not reduce the intrinsic QRS duration, it can delay negative ventricular electrical remodeling. Continuous CRT is necessary.
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Affiliation(s)
- Jianghua Zhang
- Department of Cardiology, First Affiliated Hospital of Xinjiang Medical University
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Gorcsan J, Sogaard P, Bax JJ, Singh JP, Abraham WT, Borer JS, Dickstein K, Gras D, Krum H, Brugada J, Robertson M, Ford I, Holzmeister J, Ruschitzka F. Association of persistent or worsened echocardiographic dyssynchrony with unfavourable clinical outcomes in heart failure patients with narrow QRS width: a subgroup analysis of the EchoCRT trial. Eur Heart J 2015; 37:49-59. [DOI: 10.1093/eurheartj/ehv418] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2015] [Accepted: 07/29/2015] [Indexed: 01/09/2023] Open
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50
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Hartlage GR, Suever JD, Clement-Guinaudeau S, Strickland PT, Ghasemzadeh N, Magrath RP, Parikh A, Lerakis S, Hoskins MH, Leon AR, Lloyd MS, Oshinski JN. Prediction of response to cardiac resynchronization therapy using left ventricular pacing lead position and cardiovascular magnetic resonance derived wall motion patterns: a prospective cohort study. J Cardiovasc Magn Reson 2015; 17:57. [PMID: 26170046 PMCID: PMC4501253 DOI: 10.1186/s12968-015-0158-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2014] [Accepted: 06/22/2015] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Despite marked benefits in many heart failure patients, a considerable proportion of patients treated with cardiac resynchronization therapy (CRT) fail to respond appropriately. Recently, a "U-shaped" (type II) wall motion pattern identified by cardiovascular magnetic resonance (CMR) has been associated with improved CRT response compared to a homogenous (type I) wall motion pattern. There is also evidence that a left ventricular (LV) lead localized to the latest contracting LV site predicts superior response, compared to an LV lead localized remotely from the latest contracting LV site. METHODS We prospectively evaluated patients undergoing CRT with pre-procedural CMR to determine the presence of type I and type II wall motion patterns and pre-procedural echocardiography to determine end systolic volume (ESV). We assessed the final LV lead position on post-procedural fluoroscopic images to determine whether the lead was positioned concordant to or remote from the latest contracting LV site. CRT response was defined as a ≥ 15% reduction in ESV on a 6 month follow-up echocardiogram. RESULTS The study included 33 patients meeting conventional indications for CRT with a mean New York Heart Association class of 2.8 ± 0.4 and mean LV ejection fraction of 28 ± 9%. Overall, 55% of patients were echocardiographic responders by ESV criteria. Patients with both a type II pattern and an LV lead concordant to the latest contracting site (T2CL) had a response rate of 92%, compared to a response rate of 33% for those without T2CL (p = 0.003). T2CL was the only independent predictor of response on multivariate analysis (odds ratio 18, 95% confidence interval 1.6-206; p = 0.018). T2CL resulted in significant incremental improvement in prediction of echocardiographic response (increase in the area under the receiver operator curve from 0.69 to 0.84; p = 0.038). CONCLUSIONS The presence of a type II wall motion pattern on CMR and a concordant LV lead predicts superior CRT response. Improving patient selection by evaluating wall motion pattern and targeting LV lead placement may ultimately improve the response rate to CRT.
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Affiliation(s)
- Gregory R Hartlage
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA, USA.
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, USA.
| | - Jonathan D Suever
- Department of Biomedical Engineering, Georgia Institute of Technology/Emory University, Atlanta, GA, USA.
| | | | - Patrick T Strickland
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, USA.
| | - Nima Ghasemzadeh
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, USA.
| | - R Patrick Magrath
- Department of Biomedical Engineering, Georgia Institute of Technology/Emory University, Atlanta, GA, USA.
| | - Ankit Parikh
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, USA.
| | - Stamatios Lerakis
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA, USA.
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, USA.
| | - Michael H Hoskins
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, USA.
| | - Angel R Leon
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, USA.
| | - Michael S Lloyd
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, USA.
| | - John N Oshinski
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA, USA.
- Department of Biomedical Engineering, Georgia Institute of Technology/Emory University, Atlanta, GA, USA.
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