1
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Zhou Z, Ma F, Zhu J, Wang J, Zhang J, Zhao D. Potential Underestimation of Left Ventricular Mechanical Dyssynchrony in Dyssynchrony and Outcomes Assessment. J Multidiscip Healthc 2024; 17:1721-1729. [PMID: 38659634 PMCID: PMC11041968 DOI: 10.2147/jmdh.s450264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 04/05/2024] [Indexed: 04/26/2024] Open
Abstract
Objective Left ventricular (LV) mechanical dyssynchrony (LVMD) is fundamental to the progression of heart failure and ventricular remodeling. The status of LVMD in different patterns of bundle branch blocks (BBB) is unclear. In this study, we analyzed the relationship between LVMD and left ventricular systolic dysfunction using real-time three-dimensional echocardiography (RT-3DE). Methods RT-3DE and conventional two-dimensional echocardiography were performed on 68 patients with left bundle branch block (LBBB group), 106 patients with right bundle branch block (RBBB group), and 103 patients without BBB (Normal group). The RT-3DE data sets provided time-volume analysis for global and segmental LV volumes. The LV systolic dyssynchrony index (LVSDI) was calculated using the standard deviation (SD) and maximal difference (Dif) of time to minimum segmental volume (tmsv) for LV segments adjusted by the R-R interval. LVMD was considered if the LVSDI (Tmsv-16-SD) was greater than or equal to 5%. Results LVSDI is negatively and significantly correlated with left ventricular ejection fraction (LVEF), but not with BBB or QRS duration. The proportion of LVMD in the LBBB, RBBB, and Normal group was 30.88%, 28.30%, and 25.24%, respectively, and there was no significant difference. Conclusion In dilated cardiomyopathy, LVMD is more closely related to LVEF reduction than QRS morphology and duration.
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Affiliation(s)
- Zhongyin Zhou
- Department of Echocardiography, Affiliated Hospital 2 of Nantong University, First People’s Hospital of Nantong City, Nantong, 226000, People’s Republic of China
| | - Feiyan Ma
- Department of Ultrasound, the People’s Hospital of Rugao, Nantong, 226000, People’s Republic of China
| | - Jianxiang Zhu
- Department of Echocardiography, Affiliated Hospital 2 of Nantong University, First People’s Hospital of Nantong City, Nantong, 226000, People’s Republic of China
| | - Jialing Wang
- Department of Echocardiography, Affiliated Hospital 2 of Nantong University, First People’s Hospital of Nantong City, Nantong, 226000, People’s Republic of China
| | - Jing Zhang
- Department of Electroencephalogram, Affiliated Hospital 2 of Nantong University, First People’s Hospital of Nantong City, Nantong, 226000, People’s Republic of China
| | - Dongsheng Zhao
- Department of Cardiology, Affiliated Hospital 2 of Nantong University, First People’s Hospital of Nantong City, Nantong, 226000, People’s Republic of China
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2
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Ueda N, Ishibashi K, Noda T, Oka S, Miyazaki Y, Shimamoto K, Wakamiya A, Nakajima K, Kamakura T, Wada M, Inoue Y, Miyamoto K, Nagase S, Aiba T, Kanzaki H, Izumi C, Noguchi T, Kusano K. Implications of ventricular arrhythmia after cardiac resynchronization therapy. Heart Rhythm 2024; 21:163-171. [PMID: 37739199 DOI: 10.1016/j.hrthm.2023.09.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Revised: 09/02/2023] [Accepted: 09/16/2023] [Indexed: 09/24/2023]
Abstract
BACKGROUND Conflicting data are available on whether ventricular arrhythmia (VA) or shock therapy increases mortality. Although cardiac resynchronization therapy (CRT) reduces the risk of VA, little is known about the prognostic value of VA among patients with CRT devices. OBJECTIVES The purpose of this study was to evaluate the implications of VA as a prognostic marker for CRT. METHODS We investigated 330 CRT patients within 1 year after CRT device implantation. The primary endpoint was the composite endpoint of all-cause death or hospitalization for heart failure. RESULTS Forty-three patients had VA events. These patients had a significantly higher risk of the primary endpoint, even among CRT responders (P = .009). Fast VA compared to slow VA was associated with an increased risk of the primary endpoint (hazard ratio [HR] 2.14; 95% confidence interval [CI] 1.06-4.34; P = .035). Shock therapy was not associated with a primary endpoint (shock therapy vs antitachycardia pacing: HR 1.49; 95% CI 0.73-3.03; P = .269). The patients with VA had a lower prevalence of response to CRT (23 [53%] vs 202 [70%]; P = .031) and longer left ventricular paced conduction time (174 ± 23 ms vs 143 ± 36 ms; P = .003) than the patients without VA. CONCLUSION VA occurrence within 1 year was related to paced electrical delay and poor response to CRT. VA could be associated with poor prognosis among CRT patients.
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Affiliation(s)
- Nobuhiko Ueda
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan.
| | - Kohei Ishibashi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Takashi Noda
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Satoshi Oka
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Yuichiro Miyazaki
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Keiko Shimamoto
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Akinori Wakamiya
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Kenzaburo Nakajima
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Tsukasa Kamakura
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Mitsuru Wada
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Yuko Inoue
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Koji Miyamoto
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Satoshi Nagase
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Takeshi Aiba
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Hideaki Kanzaki
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Chisato Izumi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Teruo Noguchi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Kengo Kusano
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
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3
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Stankovic I, Voigt JU, Burri H, Muraru D, Sade LE, Haugaa KH, Lumens J, Biffi M, Dacher JN, Marsan NA, Bakelants E, Manisty C, Dweck MR, Smiseth OA, Donal E. Imaging in patients with cardiovascular implantable electronic devices: part 1-imaging before and during device implantation. A clinical consensus statement of the European Association of Cardiovascular Imaging (EACVI) and the European Heart Rhythm Association (EHRA) of the ESC. Eur Heart J Cardiovasc Imaging 2023; 25:e1-e32. [PMID: 37861372 DOI: 10.1093/ehjci/jead272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2023] [Revised: 10/15/2023] [Accepted: 10/15/2023] [Indexed: 10/21/2023] Open
Abstract
More than 500 000 cardiovascular implantable electronic devices (CIEDs) are implanted in the European Society of Cardiology countries each year. The role of cardiovascular imaging in patients being considered for CIED is distinctly different from imaging in CIED recipients. In the former group, imaging can help identify specific or potentially reversible causes of heart block, the underlying tissue characteristics associated with malignant arrhythmias, and the mechanical consequences of conduction delays and can also aid challenging lead placements. On the other hand, cardiovascular imaging is required in CIED recipients for standard indications and to assess the response to device implantation, to diagnose immediate and delayed complications after implantation, and to guide device optimization. The present clinical consensus statement (Part 1) from the European Association of Cardiovascular Imaging, in collaboration with the European Heart Rhythm Association, provides comprehensive, up-to-date, and evidence-based guidance to cardiologists, cardiac imagers, and pacing specialists regarding the use of imaging in patients undergoing implantation of conventional pacemakers, cardioverter defibrillators, and resynchronization therapy devices. The document summarizes the existing evidence regarding the use of imaging in patient selection and during the implantation procedure and also underlines gaps in evidence in the field. The role of imaging after CIED implantation is discussed in the second document (Part 2).
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Affiliation(s)
- Ivan Stankovic
- Clinical Hospital Centre Zemun, Department of Cardiology, Faculty of Medicine, University of Belgrade, Vukova 9, 11080 Belgrade, Serbia
| | - Jens-Uwe Voigt
- Department of Cardiovascular Diseases, University Hospitals Leuven/Department of Cardiovascular Sciences, Catholic University of Leuven, Herestraat 49, Leuven 3000, Belgium
| | - Haran Burri
- Cardiac Pacing Unit, Cardiology Department, University Hospital of Geneva, Geneva, Switzerland
| | - Denisa Muraru
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Milan, Italy
| | - Leyla Elif Sade
- University of Pittsburgh Medical Center, Heart and Vascular Institute, Pittsburgh, PA, USA
- Department of Cardiology, University of Baskent, Ankara, Turkey
| | - Kristina Hermann Haugaa
- ProCardio Center for Innovation, Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
- Faculty of Medicine Karolinska Institutet AND Cardiovascular Division, Karolinska University Hospital, StockholmSweden
| | - Joost Lumens
- Cardiovascular Research Center Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - Mauro Biffi
- Department of Cardiology, IRCCS, Azienda Ospedaliero Universitaria Di Bologna, Policlinico Di S.Orsola, Bologna, Italy
| | - Jean-Nicolas Dacher
- Department of Radiology, Normandie University, UNIROUEN, INSERM U1096 - Rouen University Hospital, F 76000 Rouen, France
| | - Nina Ajmone Marsan
- Department of Cardiology, Heart and Lung Center, Leiden University Medical Center, Leiden, The Netherlands
| | - Elise Bakelants
- Cardiac Pacing Unit, Cardiology Department, University Hospital of Geneva, Geneva, Switzerland
| | - Charlotte Manisty
- Department of Cardiovascular Imaging, Barts Heart Centre, Barts Health NHS Trust, London, UK
- Institute of Cardiovascular Science, University College London, London, UK
| | - Marc R Dweck
- Centre for Cardiovascular Science, University of Edinburgh, Little France Crescent, Edinburgh EH16 4SB, United Kingdom
| | - Otto A Smiseth
- Institute for Surgical Research, Oslo University Hospital and University of Oslo, Oslo, Norway
| | - Erwan Donal
- University of Rennes, CHU Rennes, Inserm, LTSI-UMR 1099, Rennes, France
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4
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Chung MK, Patton KK, Lau CP, Dal Forno ARJ, Al-Khatib SM, Arora V, Birgersdotter-Green UM, Cha YM, Chung EH, Cronin EM, Curtis AB, Cygankiewicz I, Dandamudi G, Dubin AM, Ensch DP, Glotzer TV, Gold MR, Goldberger ZD, Gopinathannair R, Gorodeski EZ, Gutierrez A, Guzman JC, Huang W, Imrey PB, Indik JH, Karim S, Karpawich PP, Khaykin Y, Kiehl EL, Kron J, Kutyifa V, Link MS, Marine JE, Mullens W, Park SJ, Parkash R, Patete MF, Pathak RK, Perona CA, Rickard J, Schoenfeld MH, Seow SC, Shen WK, Shoda M, Singh JP, Slotwiner DJ, Sridhar ARM, Srivatsa UN, Stecker EC, Tanawuttiwat T, Tang WHW, Tapias CA, Tracy CM, Upadhyay GA, Varma N, Vernooy K, Vijayaraman P, Worsnick SA, Zareba W, Zeitler EP, Lopez-Cabanillas N, Ellenbogen KA, Hua W, Ikeda T, Mackall JA, Mason PK, McLeod CJ, Mela T, Moore JP, Racenet LK. 2023 HRS/APHRS/LAHRS guideline on cardiac physiologic pacing for the avoidance and mitigation of heart failure. J Arrhythm 2023; 39:681-756. [PMID: 37799799 PMCID: PMC10549836 DOI: 10.1002/joa3.12872] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/07/2023] Open
Abstract
Cardiac physiologic pacing (CPP), encompassing cardiac resynchronization therapy (CRT) and conduction system pacing (CSP), has emerged as a pacing therapy strategy that may mitigate or prevent the development of heart failure (HF) in patients with ventricular dyssynchrony or pacing-induced cardiomyopathy. This clinical practice guideline is intended to provide guidance on indications for CRT for HF therapy and CPP in patients with pacemaker indications or HF, patient selection, pre-procedure evaluation and preparation, implant procedure management, follow-up evaluation and optimization of CPP response, and use in pediatric populations. Gaps in knowledge, pointing to new directions for future research, are also identified.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Eugene H Chung
- University of Michigan Medical School Ann Arbor Michigan USA
| | | | | | | | | | - Anne M Dubin
- Stanford University, Pediatric Cardiology Palo Alto California USA
| | - Douglas P Ensch
- Cleveland Clinic Cleveland Ohio USA
- University of Washington Seattle Washington USA
- University of Hong Kong Hong Kong China
- Hospital SOS Cárdio Florianópolis Brazil
- Duke University Medical Center Durham North Carolina USA
- Indraprastha Apollo Hospital New Delhi India
- University of California San Diego Health La Jolla California USA
- Mayo Clinic, Rochester Rochester Minnesota USA
- University of Michigan Medical School Ann Arbor Michigan USA
- Temple University Philadelphia Pennsylvania USA
- University at Buffalo Buffalo New York USA
- Medical University of Łódź, Łódź Poland
- Virginia Mason Franciscan Health Tacoma Washington USA
- Stanford University, Pediatric Cardiology Palo Alto California USA
- Hackensack Meridian School of Medicine Hackensack New Jersey USA
- Medical University of South Carolina Charleston South Carolina USA
- University of Wisconsin School of Medicine and Public Health Madison Wisconsin USA
- Kansas City Heart Rhythm Institute Overland Park Kansas USA
- University Hospitals and Case Western Reserve University School of Medicine Cleveland Ohio USA
- University of Minnesota Minneapolis Minnesota USA
- McMaster University Hamilton Ontario Canada
- First Affiliated Hospital of Wenzhou Medical University Wenzhou China
- Case Western Reserve University Cleveland Ohio USA
- University of Arizona, Sarver Heart Center Tucson Arizona USA
- MetroHealth Medical Center Case Western Reserve University Cleveland Ohio USA
- The Children's Hospital of Michigan Central Michigan University Detroit Michigan USA
- Southlake Regional Health Center Newmarket Ontario Canada
- Sentara Norfolk Virginia USA
- Virginia Commonwealth University Richmond Virginia USA
- University of Rochester Medical Center Rochester New York USA
- University of Texas Southwestern Medical Center Dallas Texas USA
- Johns Hopkins University School of Medicine Baltimore Maryland USA
- Ziekenhuis Oost-Limburg Genk Belgium and Hasselt University Hasselt Belgium
- Sungkyunkwan University School of Medicine, Samsung Medical Center Seoul Republic of Korea
- QEII Health Sciences Center Halifax Nova Scotia Canada
- Clinica Corazones Unidos Santo Domingo Dominican Republic
- Australian National University, Canberra Hospital Garran Australian Capital Territory Australia
- Santojanni Hospital Buenos Aires Argentina
- Yale University School of Medicine New Haven Connecticut USA
- National University Hospital Singapore Singapore
- Mayo Clinic Phoenix Arizona USA
- Tokyo Women's Medical University Tokyo Japan
- Massachusetts General Hospital, Harvard Medical School Boston Massachusetts USA
- Weill Cornell Medicine Population Health Sciences New York New York USA
- University of California Davis Sacramento California USA
- Oregon Health & Science University Portland Oregon USA
- Indiana University Indianapolis Indiana USA
- Fundación Cardioinfantil Instituto de Cardiologia Bogotá Colombia
- George Washington University Washington District of Columbia USA
- University of Chicago Medicine Chicago Illinois USA
- Cardiovascular Research Institute Maastricht, Maastricht University Medical Center Maastricht The Netherlands
- Geisinger Health System Wilkes-Barre Pennsylvania USA
- Dartmouth Hitchcock Medical Center New Hampshire Lebanon
| | - Taya V Glotzer
- Hackensack Meridian School of Medicine Hackensack New Jersey USA
| | - Michael R Gold
- Medical University of South Carolina Charleston South Carolina USA
| | - Zachary D Goldberger
- University of Wisconsin School of Medicine and Public Health Madison Wisconsin USA
| | | | - Eiran Z Gorodeski
- University Hospitals and Case Western Reserve University School of Medicine Cleveland Ohio USA
| | | | | | - Weijian Huang
- First Affiliated Hospital of Wenzhou Medical University Wenzhou China
| | - Peter B Imrey
- Cleveland Clinic Cleveland Ohio USA
- Case Western Reserve University Cleveland Ohio USA
| | - Julia H Indik
- University of Arizona, Sarver Heart Center Tucson Arizona USA
| | - Saima Karim
- MetroHealth Medical Center Case Western Reserve University Cleveland Ohio USA
| | - Peter P Karpawich
- The Children's Hospital of Michigan Central Michigan University Detroit Michigan USA
| | - Yaariv Khaykin
- Southlake Regional Health Center Newmarket Ontario Canada
| | | | - Jordana Kron
- Virginia Commonwealth University Richmond Virginia USA
| | | | - Mark S Link
- University of Texas Southwestern Medical Center Dallas Texas USA
| | - Joseph E Marine
- Johns Hopkins University School of Medicine Baltimore Maryland USA
| | - Wilfried Mullens
- Ziekenhuis Oost-Limburg Genk Belgium and Hasselt University Hasselt Belgium
| | - Seung-Jung Park
- Sungkyunkwan University School of Medicine, Samsung Medical Center Seoul Republic of Korea
| | | | | | - Rajeev Kumar Pathak
- Australian National University, Canberra Hospital Garran Australian Capital Territory Australia
| | | | | | | | | | | | - Morio Shoda
- Tokyo Women's Medical University Tokyo Japan
| | - Jagmeet P Singh
- Massachusetts General Hospital, Harvard Medical School Boston Massachusetts USA
| | - David J Slotwiner
- Weill Cornell Medicine Population Health Sciences New York New York USA
| | | | - Uma N Srivatsa
- University of California Davis Sacramento California USA
| | | | | | | | | | - Cynthia M Tracy
- George Washington University Washington District of Columbia USA
| | | | | | - Kevin Vernooy
- Cardiovascular Research Institute Maastricht, Maastricht University Medical Center Maastricht The Netherlands
| | | | | | - Wojciech Zareba
- University of Rochester Medical Center Rochester New York USA
| | | | - Nestor Lopez-Cabanillas
- Cleveland Clinic Cleveland Ohio USA
- University of Washington Seattle Washington USA
- University of Hong Kong Hong Kong China
- Hospital SOS Cárdio Florianópolis Brazil
- Duke University Medical Center Durham North Carolina USA
- Indraprastha Apollo Hospital New Delhi India
- University of California San Diego Health La Jolla California USA
- Mayo Clinic, Rochester Rochester Minnesota USA
- University of Michigan Medical School Ann Arbor Michigan USA
- Temple University Philadelphia Pennsylvania USA
- University at Buffalo Buffalo New York USA
- Medical University of Łódź, Łódź Poland
- Virginia Mason Franciscan Health Tacoma Washington USA
- Stanford University, Pediatric Cardiology Palo Alto California USA
- Hackensack Meridian School of Medicine Hackensack New Jersey USA
- Medical University of South Carolina Charleston South Carolina USA
- University of Wisconsin School of Medicine and Public Health Madison Wisconsin USA
- Kansas City Heart Rhythm Institute Overland Park Kansas USA
- University Hospitals and Case Western Reserve University School of Medicine Cleveland Ohio USA
- University of Minnesota Minneapolis Minnesota USA
- McMaster University Hamilton Ontario Canada
- First Affiliated Hospital of Wenzhou Medical University Wenzhou China
- Case Western Reserve University Cleveland Ohio USA
- University of Arizona, Sarver Heart Center Tucson Arizona USA
- MetroHealth Medical Center Case Western Reserve University Cleveland Ohio USA
- The Children's Hospital of Michigan Central Michigan University Detroit Michigan USA
- Southlake Regional Health Center Newmarket Ontario Canada
- Sentara Norfolk Virginia USA
- Virginia Commonwealth University Richmond Virginia USA
- University of Rochester Medical Center Rochester New York USA
- University of Texas Southwestern Medical Center Dallas Texas USA
- Johns Hopkins University School of Medicine Baltimore Maryland USA
- Ziekenhuis Oost-Limburg Genk Belgium and Hasselt University Hasselt Belgium
- Sungkyunkwan University School of Medicine, Samsung Medical Center Seoul Republic of Korea
- QEII Health Sciences Center Halifax Nova Scotia Canada
- Clinica Corazones Unidos Santo Domingo Dominican Republic
- Australian National University, Canberra Hospital Garran Australian Capital Territory Australia
- Santojanni Hospital Buenos Aires Argentina
- Yale University School of Medicine New Haven Connecticut USA
- National University Hospital Singapore Singapore
- Mayo Clinic Phoenix Arizona USA
- Tokyo Women's Medical University Tokyo Japan
- Massachusetts General Hospital, Harvard Medical School Boston Massachusetts USA
- Weill Cornell Medicine Population Health Sciences New York New York USA
- University of California Davis Sacramento California USA
- Oregon Health & Science University Portland Oregon USA
- Indiana University Indianapolis Indiana USA
- Fundación Cardioinfantil Instituto de Cardiologia Bogotá Colombia
- George Washington University Washington District of Columbia USA
- University of Chicago Medicine Chicago Illinois USA
- Cardiovascular Research Institute Maastricht, Maastricht University Medical Center Maastricht The Netherlands
- Geisinger Health System Wilkes-Barre Pennsylvania USA
- Dartmouth Hitchcock Medical Center New Hampshire Lebanon
| | - Kenneth A Ellenbogen
- Cleveland Clinic Cleveland Ohio USA
- University of Washington Seattle Washington USA
- University of Hong Kong Hong Kong China
- Hospital SOS Cárdio Florianópolis Brazil
- Duke University Medical Center Durham North Carolina USA
- Indraprastha Apollo Hospital New Delhi India
- University of California San Diego Health La Jolla California USA
- Mayo Clinic, Rochester Rochester Minnesota USA
- University of Michigan Medical School Ann Arbor Michigan USA
- Temple University Philadelphia Pennsylvania USA
- University at Buffalo Buffalo New York USA
- Medical University of Łódź, Łódź Poland
- Virginia Mason Franciscan Health Tacoma Washington USA
- Stanford University, Pediatric Cardiology Palo Alto California USA
- Hackensack Meridian School of Medicine Hackensack New Jersey USA
- Medical University of South Carolina Charleston South Carolina USA
- University of Wisconsin School of Medicine and Public Health Madison Wisconsin USA
- Kansas City Heart Rhythm Institute Overland Park Kansas USA
- University Hospitals and Case Western Reserve University School of Medicine Cleveland Ohio USA
- University of Minnesota Minneapolis Minnesota USA
- McMaster University Hamilton Ontario Canada
- First Affiliated Hospital of Wenzhou Medical University Wenzhou China
- Case Western Reserve University Cleveland Ohio USA
- University of Arizona, Sarver Heart Center Tucson Arizona USA
- MetroHealth Medical Center Case Western Reserve University Cleveland Ohio USA
- The Children's Hospital of Michigan Central Michigan University Detroit Michigan USA
- Southlake Regional Health Center Newmarket Ontario Canada
- Sentara Norfolk Virginia USA
- Virginia Commonwealth University Richmond Virginia USA
- University of Rochester Medical Center Rochester New York USA
- University of Texas Southwestern Medical Center Dallas Texas USA
- Johns Hopkins University School of Medicine Baltimore Maryland USA
- Ziekenhuis Oost-Limburg Genk Belgium and Hasselt University Hasselt Belgium
- Sungkyunkwan University School of Medicine, Samsung Medical Center Seoul Republic of Korea
- QEII Health Sciences Center Halifax Nova Scotia Canada
- Clinica Corazones Unidos Santo Domingo Dominican Republic
- Australian National University, Canberra Hospital Garran Australian Capital Territory Australia
- Santojanni Hospital Buenos Aires Argentina
- Yale University School of Medicine New Haven Connecticut USA
- National University Hospital Singapore Singapore
- Mayo Clinic Phoenix Arizona USA
- Tokyo Women's Medical University Tokyo Japan
- Massachusetts General Hospital, Harvard Medical School Boston Massachusetts USA
- Weill Cornell Medicine Population Health Sciences New York New York USA
- University of California Davis Sacramento California USA
- Oregon Health & Science University Portland Oregon USA
- Indiana University Indianapolis Indiana USA
- Fundación Cardioinfantil Instituto de Cardiologia Bogotá Colombia
- George Washington University Washington District of Columbia USA
- University of Chicago Medicine Chicago Illinois USA
- Cardiovascular Research Institute Maastricht, Maastricht University Medical Center Maastricht The Netherlands
- Geisinger Health System Wilkes-Barre Pennsylvania USA
- Dartmouth Hitchcock Medical Center New Hampshire Lebanon
| | - Wei Hua
- Cleveland Clinic Cleveland Ohio USA
- University of Washington Seattle Washington USA
- University of Hong Kong Hong Kong China
- Hospital SOS Cárdio Florianópolis Brazil
- Duke University Medical Center Durham North Carolina USA
- Indraprastha Apollo Hospital New Delhi India
- University of California San Diego Health La Jolla California USA
- Mayo Clinic, Rochester Rochester Minnesota USA
- University of Michigan Medical School Ann Arbor Michigan USA
- Temple University Philadelphia Pennsylvania USA
- University at Buffalo Buffalo New York USA
- Medical University of Łódź, Łódź Poland
- Virginia Mason Franciscan Health Tacoma Washington USA
- Stanford University, Pediatric Cardiology Palo Alto California USA
- Hackensack Meridian School of Medicine Hackensack New Jersey USA
- Medical University of South Carolina Charleston South Carolina USA
- University of Wisconsin School of Medicine and Public Health Madison Wisconsin USA
- Kansas City Heart Rhythm Institute Overland Park Kansas USA
- University Hospitals and Case Western Reserve University School of Medicine Cleveland Ohio USA
- University of Minnesota Minneapolis Minnesota USA
- McMaster University Hamilton Ontario Canada
- First Affiliated Hospital of Wenzhou Medical University Wenzhou China
- Case Western Reserve University Cleveland Ohio USA
- University of Arizona, Sarver Heart Center Tucson Arizona USA
- MetroHealth Medical Center Case Western Reserve University Cleveland Ohio USA
- The Children's Hospital of Michigan Central Michigan University Detroit Michigan USA
- Southlake Regional Health Center Newmarket Ontario Canada
- Sentara Norfolk Virginia USA
- Virginia Commonwealth University Richmond Virginia USA
- University of Rochester Medical Center Rochester New York USA
- University of Texas Southwestern Medical Center Dallas Texas USA
- Johns Hopkins University School of Medicine Baltimore Maryland USA
- Ziekenhuis Oost-Limburg Genk Belgium and Hasselt University Hasselt Belgium
- Sungkyunkwan University School of Medicine, Samsung Medical Center Seoul Republic of Korea
- QEII Health Sciences Center Halifax Nova Scotia Canada
- Clinica Corazones Unidos Santo Domingo Dominican Republic
- Australian National University, Canberra Hospital Garran Australian Capital Territory Australia
- Santojanni Hospital Buenos Aires Argentina
- Yale University School of Medicine New Haven Connecticut USA
- National University Hospital Singapore Singapore
- Mayo Clinic Phoenix Arizona USA
- Tokyo Women's Medical University Tokyo Japan
- Massachusetts General Hospital, Harvard Medical School Boston Massachusetts USA
- Weill Cornell Medicine Population Health Sciences New York New York USA
- University of California Davis Sacramento California USA
- Oregon Health & Science University Portland Oregon USA
- Indiana University Indianapolis Indiana USA
- Fundación Cardioinfantil Instituto de Cardiologia Bogotá Colombia
- George Washington University Washington District of Columbia USA
- University of Chicago Medicine Chicago Illinois USA
- Cardiovascular Research Institute Maastricht, Maastricht University Medical Center Maastricht The Netherlands
- Geisinger Health System Wilkes-Barre Pennsylvania USA
- Dartmouth Hitchcock Medical Center New Hampshire Lebanon
| | - Takanori Ikeda
- Cleveland Clinic Cleveland Ohio USA
- University of Washington Seattle Washington USA
- University of Hong Kong Hong Kong China
- Hospital SOS Cárdio Florianópolis Brazil
- Duke University Medical Center Durham North Carolina USA
- Indraprastha Apollo Hospital New Delhi India
- University of California San Diego Health La Jolla California USA
- Mayo Clinic, Rochester Rochester Minnesota USA
- University of Michigan Medical School Ann Arbor Michigan USA
- Temple University Philadelphia Pennsylvania USA
- University at Buffalo Buffalo New York USA
- Medical University of Łódź, Łódź Poland
- Virginia Mason Franciscan Health Tacoma Washington USA
- Stanford University, Pediatric Cardiology Palo Alto California USA
- Hackensack Meridian School of Medicine Hackensack New Jersey USA
- Medical University of South Carolina Charleston South Carolina USA
- University of Wisconsin School of Medicine and Public Health Madison Wisconsin USA
- Kansas City Heart Rhythm Institute Overland Park Kansas USA
- University Hospitals and Case Western Reserve University School of Medicine Cleveland Ohio USA
- University of Minnesota Minneapolis Minnesota USA
- McMaster University Hamilton Ontario Canada
- First Affiliated Hospital of Wenzhou Medical University Wenzhou China
- Case Western Reserve University Cleveland Ohio USA
- University of Arizona, Sarver Heart Center Tucson Arizona USA
- MetroHealth Medical Center Case Western Reserve University Cleveland Ohio USA
- The Children's Hospital of Michigan Central Michigan University Detroit Michigan USA
- Southlake Regional Health Center Newmarket Ontario Canada
- Sentara Norfolk Virginia USA
- Virginia Commonwealth University Richmond Virginia USA
- University of Rochester Medical Center Rochester New York USA
- University of Texas Southwestern Medical Center Dallas Texas USA
- Johns Hopkins University School of Medicine Baltimore Maryland USA
- Ziekenhuis Oost-Limburg Genk Belgium and Hasselt University Hasselt Belgium
- Sungkyunkwan University School of Medicine, Samsung Medical Center Seoul Republic of Korea
- QEII Health Sciences Center Halifax Nova Scotia Canada
- Clinica Corazones Unidos Santo Domingo Dominican Republic
- Australian National University, Canberra Hospital Garran Australian Capital Territory Australia
- Santojanni Hospital Buenos Aires Argentina
- Yale University School of Medicine New Haven Connecticut USA
- National University Hospital Singapore Singapore
- Mayo Clinic Phoenix Arizona USA
- Tokyo Women's Medical University Tokyo Japan
- Massachusetts General Hospital, Harvard Medical School Boston Massachusetts USA
- Weill Cornell Medicine Population Health Sciences New York New York USA
- University of California Davis Sacramento California USA
- Oregon Health & Science University Portland Oregon USA
- Indiana University Indianapolis Indiana USA
- Fundación Cardioinfantil Instituto de Cardiologia Bogotá Colombia
- George Washington University Washington District of Columbia USA
- University of Chicago Medicine Chicago Illinois USA
- Cardiovascular Research Institute Maastricht, Maastricht University Medical Center Maastricht The Netherlands
- Geisinger Health System Wilkes-Barre Pennsylvania USA
- Dartmouth Hitchcock Medical Center New Hampshire Lebanon
| | - Judith A Mackall
- Cleveland Clinic Cleveland Ohio USA
- University of Washington Seattle Washington USA
- University of Hong Kong Hong Kong China
- Hospital SOS Cárdio Florianópolis Brazil
- Duke University Medical Center Durham North Carolina USA
- Indraprastha Apollo Hospital New Delhi India
- University of California San Diego Health La Jolla California USA
- Mayo Clinic, Rochester Rochester Minnesota USA
- University of Michigan Medical School Ann Arbor Michigan USA
- Temple University Philadelphia Pennsylvania USA
- University at Buffalo Buffalo New York USA
- Medical University of Łódź, Łódź Poland
- Virginia Mason Franciscan Health Tacoma Washington USA
- Stanford University, Pediatric Cardiology Palo Alto California USA
- Hackensack Meridian School of Medicine Hackensack New Jersey USA
- Medical University of South Carolina Charleston South Carolina USA
- University of Wisconsin School of Medicine and Public Health Madison Wisconsin USA
- Kansas City Heart Rhythm Institute Overland Park Kansas USA
- University Hospitals and Case Western Reserve University School of Medicine Cleveland Ohio USA
- University of Minnesota Minneapolis Minnesota USA
- McMaster University Hamilton Ontario Canada
- First Affiliated Hospital of Wenzhou Medical University Wenzhou China
- Case Western Reserve University Cleveland Ohio USA
- University of Arizona, Sarver Heart Center Tucson Arizona USA
- MetroHealth Medical Center Case Western Reserve University Cleveland Ohio USA
- The Children's Hospital of Michigan Central Michigan University Detroit Michigan USA
- Southlake Regional Health Center Newmarket Ontario Canada
- Sentara Norfolk Virginia USA
- Virginia Commonwealth University Richmond Virginia USA
- University of Rochester Medical Center Rochester New York USA
- University of Texas Southwestern Medical Center Dallas Texas USA
- Johns Hopkins University School of Medicine Baltimore Maryland USA
- Ziekenhuis Oost-Limburg Genk Belgium and Hasselt University Hasselt Belgium
- Sungkyunkwan University School of Medicine, Samsung Medical Center Seoul Republic of Korea
- QEII Health Sciences Center Halifax Nova Scotia Canada
- Clinica Corazones Unidos Santo Domingo Dominican Republic
- Australian National University, Canberra Hospital Garran Australian Capital Territory Australia
- Santojanni Hospital Buenos Aires Argentina
- Yale University School of Medicine New Haven Connecticut USA
- National University Hospital Singapore Singapore
- Mayo Clinic Phoenix Arizona USA
- Tokyo Women's Medical University Tokyo Japan
- Massachusetts General Hospital, Harvard Medical School Boston Massachusetts USA
- Weill Cornell Medicine Population Health Sciences New York New York USA
- University of California Davis Sacramento California USA
- Oregon Health & Science University Portland Oregon USA
- Indiana University Indianapolis Indiana USA
- Fundación Cardioinfantil Instituto de Cardiologia Bogotá Colombia
- George Washington University Washington District of Columbia USA
- University of Chicago Medicine Chicago Illinois USA
- Cardiovascular Research Institute Maastricht, Maastricht University Medical Center Maastricht The Netherlands
- Geisinger Health System Wilkes-Barre Pennsylvania USA
- Dartmouth Hitchcock Medical Center New Hampshire Lebanon
| | - Pamela K Mason
- Cleveland Clinic Cleveland Ohio USA
- University of Washington Seattle Washington USA
- University of Hong Kong Hong Kong China
- Hospital SOS Cárdio Florianópolis Brazil
- Duke University Medical Center Durham North Carolina USA
- Indraprastha Apollo Hospital New Delhi India
- University of California San Diego Health La Jolla California USA
- Mayo Clinic, Rochester Rochester Minnesota USA
- University of Michigan Medical School Ann Arbor Michigan USA
- Temple University Philadelphia Pennsylvania USA
- University at Buffalo Buffalo New York USA
- Medical University of Łódź, Łódź Poland
- Virginia Mason Franciscan Health Tacoma Washington USA
- Stanford University, Pediatric Cardiology Palo Alto California USA
- Hackensack Meridian School of Medicine Hackensack New Jersey USA
- Medical University of South Carolina Charleston South Carolina USA
- University of Wisconsin School of Medicine and Public Health Madison Wisconsin USA
- Kansas City Heart Rhythm Institute Overland Park Kansas USA
- University Hospitals and Case Western Reserve University School of Medicine Cleveland Ohio USA
- University of Minnesota Minneapolis Minnesota USA
- McMaster University Hamilton Ontario Canada
- First Affiliated Hospital of Wenzhou Medical University Wenzhou China
- Case Western Reserve University Cleveland Ohio USA
- University of Arizona, Sarver Heart Center Tucson Arizona USA
- MetroHealth Medical Center Case Western Reserve University Cleveland Ohio USA
- The Children's Hospital of Michigan Central Michigan University Detroit Michigan USA
- Southlake Regional Health Center Newmarket Ontario Canada
- Sentara Norfolk Virginia USA
- Virginia Commonwealth University Richmond Virginia USA
- University of Rochester Medical Center Rochester New York USA
- University of Texas Southwestern Medical Center Dallas Texas USA
- Johns Hopkins University School of Medicine Baltimore Maryland USA
- Ziekenhuis Oost-Limburg Genk Belgium and Hasselt University Hasselt Belgium
- Sungkyunkwan University School of Medicine, Samsung Medical Center Seoul Republic of Korea
- QEII Health Sciences Center Halifax Nova Scotia Canada
- Clinica Corazones Unidos Santo Domingo Dominican Republic
- Australian National University, Canberra Hospital Garran Australian Capital Territory Australia
- Santojanni Hospital Buenos Aires Argentina
- Yale University School of Medicine New Haven Connecticut USA
- National University Hospital Singapore Singapore
- Mayo Clinic Phoenix Arizona USA
- Tokyo Women's Medical University Tokyo Japan
- Massachusetts General Hospital, Harvard Medical School Boston Massachusetts USA
- Weill Cornell Medicine Population Health Sciences New York New York USA
- University of California Davis Sacramento California USA
- Oregon Health & Science University Portland Oregon USA
- Indiana University Indianapolis Indiana USA
- Fundación Cardioinfantil Instituto de Cardiologia Bogotá Colombia
- George Washington University Washington District of Columbia USA
- University of Chicago Medicine Chicago Illinois USA
- Cardiovascular Research Institute Maastricht, Maastricht University Medical Center Maastricht The Netherlands
- Geisinger Health System Wilkes-Barre Pennsylvania USA
- Dartmouth Hitchcock Medical Center New Hampshire Lebanon
| | - Christopher J McLeod
- Cleveland Clinic Cleveland Ohio USA
- University of Washington Seattle Washington USA
- University of Hong Kong Hong Kong China
- Hospital SOS Cárdio Florianópolis Brazil
- Duke University Medical Center Durham North Carolina USA
- Indraprastha Apollo Hospital New Delhi India
- University of California San Diego Health La Jolla California USA
- Mayo Clinic, Rochester Rochester Minnesota USA
- University of Michigan Medical School Ann Arbor Michigan USA
- Temple University Philadelphia Pennsylvania USA
- University at Buffalo Buffalo New York USA
- Medical University of Łódź, Łódź Poland
- Virginia Mason Franciscan Health Tacoma Washington USA
- Stanford University, Pediatric Cardiology Palo Alto California USA
- Hackensack Meridian School of Medicine Hackensack New Jersey USA
- Medical University of South Carolina Charleston South Carolina USA
- University of Wisconsin School of Medicine and Public Health Madison Wisconsin USA
- Kansas City Heart Rhythm Institute Overland Park Kansas USA
- University Hospitals and Case Western Reserve University School of Medicine Cleveland Ohio USA
- University of Minnesota Minneapolis Minnesota USA
- McMaster University Hamilton Ontario Canada
- First Affiliated Hospital of Wenzhou Medical University Wenzhou China
- Case Western Reserve University Cleveland Ohio USA
- University of Arizona, Sarver Heart Center Tucson Arizona USA
- MetroHealth Medical Center Case Western Reserve University Cleveland Ohio USA
- The Children's Hospital of Michigan Central Michigan University Detroit Michigan USA
- Southlake Regional Health Center Newmarket Ontario Canada
- Sentara Norfolk Virginia USA
- Virginia Commonwealth University Richmond Virginia USA
- University of Rochester Medical Center Rochester New York USA
- University of Texas Southwestern Medical Center Dallas Texas USA
- Johns Hopkins University School of Medicine Baltimore Maryland USA
- Ziekenhuis Oost-Limburg Genk Belgium and Hasselt University Hasselt Belgium
- Sungkyunkwan University School of Medicine, Samsung Medical Center Seoul Republic of Korea
- QEII Health Sciences Center Halifax Nova Scotia Canada
- Clinica Corazones Unidos Santo Domingo Dominican Republic
- Australian National University, Canberra Hospital Garran Australian Capital Territory Australia
- Santojanni Hospital Buenos Aires Argentina
- Yale University School of Medicine New Haven Connecticut USA
- National University Hospital Singapore Singapore
- Mayo Clinic Phoenix Arizona USA
- Tokyo Women's Medical University Tokyo Japan
- Massachusetts General Hospital, Harvard Medical School Boston Massachusetts USA
- Weill Cornell Medicine Population Health Sciences New York New York USA
- University of California Davis Sacramento California USA
- Oregon Health & Science University Portland Oregon USA
- Indiana University Indianapolis Indiana USA
- Fundación Cardioinfantil Instituto de Cardiologia Bogotá Colombia
- George Washington University Washington District of Columbia USA
- University of Chicago Medicine Chicago Illinois USA
- Cardiovascular Research Institute Maastricht, Maastricht University Medical Center Maastricht The Netherlands
- Geisinger Health System Wilkes-Barre Pennsylvania USA
- Dartmouth Hitchcock Medical Center New Hampshire Lebanon
| | - Theofanie Mela
- Cleveland Clinic Cleveland Ohio USA
- University of Washington Seattle Washington USA
- University of Hong Kong Hong Kong China
- Hospital SOS Cárdio Florianópolis Brazil
- Duke University Medical Center Durham North Carolina USA
- Indraprastha Apollo Hospital New Delhi India
- University of California San Diego Health La Jolla California USA
- Mayo Clinic, Rochester Rochester Minnesota USA
- University of Michigan Medical School Ann Arbor Michigan USA
- Temple University Philadelphia Pennsylvania USA
- University at Buffalo Buffalo New York USA
- Medical University of Łódź, Łódź Poland
- Virginia Mason Franciscan Health Tacoma Washington USA
- Stanford University, Pediatric Cardiology Palo Alto California USA
- Hackensack Meridian School of Medicine Hackensack New Jersey USA
- Medical University of South Carolina Charleston South Carolina USA
- University of Wisconsin School of Medicine and Public Health Madison Wisconsin USA
- Kansas City Heart Rhythm Institute Overland Park Kansas USA
- University Hospitals and Case Western Reserve University School of Medicine Cleveland Ohio USA
- University of Minnesota Minneapolis Minnesota USA
- McMaster University Hamilton Ontario Canada
- First Affiliated Hospital of Wenzhou Medical University Wenzhou China
- Case Western Reserve University Cleveland Ohio USA
- University of Arizona, Sarver Heart Center Tucson Arizona USA
- MetroHealth Medical Center Case Western Reserve University Cleveland Ohio USA
- The Children's Hospital of Michigan Central Michigan University Detroit Michigan USA
- Southlake Regional Health Center Newmarket Ontario Canada
- Sentara Norfolk Virginia USA
- Virginia Commonwealth University Richmond Virginia USA
- University of Rochester Medical Center Rochester New York USA
- University of Texas Southwestern Medical Center Dallas Texas USA
- Johns Hopkins University School of Medicine Baltimore Maryland USA
- Ziekenhuis Oost-Limburg Genk Belgium and Hasselt University Hasselt Belgium
- Sungkyunkwan University School of Medicine, Samsung Medical Center Seoul Republic of Korea
- QEII Health Sciences Center Halifax Nova Scotia Canada
- Clinica Corazones Unidos Santo Domingo Dominican Republic
- Australian National University, Canberra Hospital Garran Australian Capital Territory Australia
- Santojanni Hospital Buenos Aires Argentina
- Yale University School of Medicine New Haven Connecticut USA
- National University Hospital Singapore Singapore
- Mayo Clinic Phoenix Arizona USA
- Tokyo Women's Medical University Tokyo Japan
- Massachusetts General Hospital, Harvard Medical School Boston Massachusetts USA
- Weill Cornell Medicine Population Health Sciences New York New York USA
- University of California Davis Sacramento California USA
- Oregon Health & Science University Portland Oregon USA
- Indiana University Indianapolis Indiana USA
- Fundación Cardioinfantil Instituto de Cardiologia Bogotá Colombia
- George Washington University Washington District of Columbia USA
- University of Chicago Medicine Chicago Illinois USA
- Cardiovascular Research Institute Maastricht, Maastricht University Medical Center Maastricht The Netherlands
- Geisinger Health System Wilkes-Barre Pennsylvania USA
- Dartmouth Hitchcock Medical Center New Hampshire Lebanon
| | - Jeremy P Moore
- Cleveland Clinic Cleveland Ohio USA
- University of Washington Seattle Washington USA
- University of Hong Kong Hong Kong China
- Hospital SOS Cárdio Florianópolis Brazil
- Duke University Medical Center Durham North Carolina USA
- Indraprastha Apollo Hospital New Delhi India
- University of California San Diego Health La Jolla California USA
- Mayo Clinic, Rochester Rochester Minnesota USA
- University of Michigan Medical School Ann Arbor Michigan USA
- Temple University Philadelphia Pennsylvania USA
- University at Buffalo Buffalo New York USA
- Medical University of Łódź, Łódź Poland
- Virginia Mason Franciscan Health Tacoma Washington USA
- Stanford University, Pediatric Cardiology Palo Alto California USA
- Hackensack Meridian School of Medicine Hackensack New Jersey USA
- Medical University of South Carolina Charleston South Carolina USA
- University of Wisconsin School of Medicine and Public Health Madison Wisconsin USA
- Kansas City Heart Rhythm Institute Overland Park Kansas USA
- University Hospitals and Case Western Reserve University School of Medicine Cleveland Ohio USA
- University of Minnesota Minneapolis Minnesota USA
- McMaster University Hamilton Ontario Canada
- First Affiliated Hospital of Wenzhou Medical University Wenzhou China
- Case Western Reserve University Cleveland Ohio USA
- University of Arizona, Sarver Heart Center Tucson Arizona USA
- MetroHealth Medical Center Case Western Reserve University Cleveland Ohio USA
- The Children's Hospital of Michigan Central Michigan University Detroit Michigan USA
- Southlake Regional Health Center Newmarket Ontario Canada
- Sentara Norfolk Virginia USA
- Virginia Commonwealth University Richmond Virginia USA
- University of Rochester Medical Center Rochester New York USA
- University of Texas Southwestern Medical Center Dallas Texas USA
- Johns Hopkins University School of Medicine Baltimore Maryland USA
- Ziekenhuis Oost-Limburg Genk Belgium and Hasselt University Hasselt Belgium
- Sungkyunkwan University School of Medicine, Samsung Medical Center Seoul Republic of Korea
- QEII Health Sciences Center Halifax Nova Scotia Canada
- Clinica Corazones Unidos Santo Domingo Dominican Republic
- Australian National University, Canberra Hospital Garran Australian Capital Territory Australia
- Santojanni Hospital Buenos Aires Argentina
- Yale University School of Medicine New Haven Connecticut USA
- National University Hospital Singapore Singapore
- Mayo Clinic Phoenix Arizona USA
- Tokyo Women's Medical University Tokyo Japan
- Massachusetts General Hospital, Harvard Medical School Boston Massachusetts USA
- Weill Cornell Medicine Population Health Sciences New York New York USA
- University of California Davis Sacramento California USA
- Oregon Health & Science University Portland Oregon USA
- Indiana University Indianapolis Indiana USA
- Fundación Cardioinfantil Instituto de Cardiologia Bogotá Colombia
- George Washington University Washington District of Columbia USA
- University of Chicago Medicine Chicago Illinois USA
- Cardiovascular Research Institute Maastricht, Maastricht University Medical Center Maastricht The Netherlands
- Geisinger Health System Wilkes-Barre Pennsylvania USA
- Dartmouth Hitchcock Medical Center New Hampshire Lebanon
| | - Laurel Kay Racenet
- Cleveland Clinic Cleveland Ohio USA
- University of Washington Seattle Washington USA
- University of Hong Kong Hong Kong China
- Hospital SOS Cárdio Florianópolis Brazil
- Duke University Medical Center Durham North Carolina USA
- Indraprastha Apollo Hospital New Delhi India
- University of California San Diego Health La Jolla California USA
- Mayo Clinic, Rochester Rochester Minnesota USA
- University of Michigan Medical School Ann Arbor Michigan USA
- Temple University Philadelphia Pennsylvania USA
- University at Buffalo Buffalo New York USA
- Medical University of Łódź, Łódź Poland
- Virginia Mason Franciscan Health Tacoma Washington USA
- Stanford University, Pediatric Cardiology Palo Alto California USA
- Hackensack Meridian School of Medicine Hackensack New Jersey USA
- Medical University of South Carolina Charleston South Carolina USA
- University of Wisconsin School of Medicine and Public Health Madison Wisconsin USA
- Kansas City Heart Rhythm Institute Overland Park Kansas USA
- University Hospitals and Case Western Reserve University School of Medicine Cleveland Ohio USA
- University of Minnesota Minneapolis Minnesota USA
- McMaster University Hamilton Ontario Canada
- First Affiliated Hospital of Wenzhou Medical University Wenzhou China
- Case Western Reserve University Cleveland Ohio USA
- University of Arizona, Sarver Heart Center Tucson Arizona USA
- MetroHealth Medical Center Case Western Reserve University Cleveland Ohio USA
- The Children's Hospital of Michigan Central Michigan University Detroit Michigan USA
- Southlake Regional Health Center Newmarket Ontario Canada
- Sentara Norfolk Virginia USA
- Virginia Commonwealth University Richmond Virginia USA
- University of Rochester Medical Center Rochester New York USA
- University of Texas Southwestern Medical Center Dallas Texas USA
- Johns Hopkins University School of Medicine Baltimore Maryland USA
- Ziekenhuis Oost-Limburg Genk Belgium and Hasselt University Hasselt Belgium
- Sungkyunkwan University School of Medicine, Samsung Medical Center Seoul Republic of Korea
- QEII Health Sciences Center Halifax Nova Scotia Canada
- Clinica Corazones Unidos Santo Domingo Dominican Republic
- Australian National University, Canberra Hospital Garran Australian Capital Territory Australia
- Santojanni Hospital Buenos Aires Argentina
- Yale University School of Medicine New Haven Connecticut USA
- National University Hospital Singapore Singapore
- Mayo Clinic Phoenix Arizona USA
- Tokyo Women's Medical University Tokyo Japan
- Massachusetts General Hospital, Harvard Medical School Boston Massachusetts USA
- Weill Cornell Medicine Population Health Sciences New York New York USA
- University of California Davis Sacramento California USA
- Oregon Health & Science University Portland Oregon USA
- Indiana University Indianapolis Indiana USA
- Fundación Cardioinfantil Instituto de Cardiologia Bogotá Colombia
- George Washington University Washington District of Columbia USA
- University of Chicago Medicine Chicago Illinois USA
- Cardiovascular Research Institute Maastricht, Maastricht University Medical Center Maastricht The Netherlands
- Geisinger Health System Wilkes-Barre Pennsylvania USA
- Dartmouth Hitchcock Medical Center New Hampshire Lebanon
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5
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Chung MK, Patton KK, Lau CP, Dal Forno ARJ, Al-Khatib SM, Arora V, Birgersdotter-Green UM, Cha YM, Chung EH, Cronin EM, Curtis AB, Cygankiewicz I, Dandamudi G, Dubin AM, Ensch DP, Glotzer TV, Gold MR, Goldberger ZD, Gopinathannair R, Gorodeski EZ, Gutierrez A, Guzman JC, Huang W, Imrey PB, Indik JH, Karim S, Karpawich PP, Khaykin Y, Kiehl EL, Kron J, Kutyifa V, Link MS, Marine JE, Mullens W, Park SJ, Parkash R, Patete MF, Pathak RK, Perona CA, Rickard J, Schoenfeld MH, Seow SC, Shen WK, Shoda M, Singh JP, Slotwiner DJ, Sridhar ARM, Srivatsa UN, Stecker EC, Tanawuttiwat T, Tang WHW, Tapias CA, Tracy CM, Upadhyay GA, Varma N, Vernooy K, Vijayaraman P, Worsnick SA, Zareba W, Zeitler EP. 2023 HRS/APHRS/LAHRS guideline on cardiac physiologic pacing for the avoidance and mitigation of heart failure. Heart Rhythm 2023; 20:e17-e91. [PMID: 37283271 PMCID: PMC11062890 DOI: 10.1016/j.hrthm.2023.03.1538] [Citation(s) in RCA: 85] [Impact Index Per Article: 85.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 03/31/2023] [Indexed: 06/08/2023]
Abstract
Cardiac physiologic pacing (CPP), encompassing cardiac resynchronization therapy (CRT) and conduction system pacing (CSP), has emerged as a pacing therapy strategy that may mitigate or prevent the development of heart failure (HF) in patients with ventricular dyssynchrony or pacing-induced cardiomyopathy. This clinical practice guideline is intended to provide guidance on indications for CRT for HF therapy and CPP in patients with pacemaker indications or HF, patient selection, pre-procedure evaluation and preparation, implant procedure management, follow-up evaluation and optimization of CPP response, and use in pediatric populations. Gaps in knowledge, pointing to new directions for future research, are also identified.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Eugene H Chung
- University of Michigan Medical School, Ann Arbor, Michigan
| | | | | | | | | | - Anne M Dubin
- Stanford University, Pediatric Cardiology, Palo Alto, California
| | | | - Taya V Glotzer
- Hackensack Meridian School of Medicine, Hackensack, New Jersey
| | - Michael R Gold
- Medical University of South Carolina, Charleston, South Carolina
| | - Zachary D Goldberger
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | | | - Eiran Z Gorodeski
- University Hospitals and Case Western Reserve University School of Medicine, Cleveland, Ohio
| | | | | | - Weijian Huang
- First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Peter B Imrey
- Cleveland Clinic, Cleveland, Ohio; Case Western Reserve University, Cleveland, Ohio
| | - Julia H Indik
- University of Arizona, Sarver Heart Center, Tucson, Arizona
| | - Saima Karim
- MetroHealth Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Peter P Karpawich
- The Children's Hospital of Michigan, Central Michigan University, Detroit, Michigan
| | - Yaariv Khaykin
- Southlake Regional Health Center, Newmarket, Ontario, Canada
| | | | - Jordana Kron
- Virginia Commonwealth University, Richmond, Virginia
| | | | - Mark S Link
- University of Texas Southwestern Medical Center, Dallas, Texas
| | - Joseph E Marine
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Wilfried Mullens
- Ziekenhuis Oost-Limburg Genk, Belgium and Hasselt University, Hasselt, Belgium
| | - Seung-Jung Park
- Sungkyunkwan University School of Medicine, Samsung Medical Center, Seoul, Republic of Korea
| | - Ratika Parkash
- QEII Health Sciences Center, Halifax, Nova Scotia, Canada
| | | | - Rajeev Kumar Pathak
- Australian National University, Canberra Hospital, Garran, Australian Capital Territory, Australia
| | | | | | | | | | | | - Morio Shoda
- Tokyo Women's Medical University, Tokyo, Japan
| | - Jagmeet P Singh
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - David J Slotwiner
- Weill Cornell Medicine Population Health Sciences, New York, New York
| | | | | | | | | | | | | | - Cynthia M Tracy
- George Washington University, Washington, District of Columbia
| | | | | | - Kevin Vernooy
- Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, Maastricht, The Netherlands
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6
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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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7
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Ciriello GD, Colonna D, Romeo E, Sarubbi B. Cardiac resynchronization therapy-defibrillator implantation guided by electroanatomic mapping in a young adult patient with congenital heart disease. Indian Pacing Electrophysiol J 2022; 22:108-111. [PMID: 35063627 PMCID: PMC8981139 DOI: 10.1016/j.ipej.2022.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Revised: 01/09/2022] [Accepted: 01/16/2022] [Indexed: 11/19/2022] Open
Abstract
Cardiac resynchronization therapy-defibrillator (CRT-D) implantation is a therapeutic option for adult patients with congenital heart disease (CHD), bundle branch block, reduced ejection fraction and symptoms of heart failure. A new implantation approach guided by the electroanatomic mapping (EAM) has been developed to overcome some issues of the standard technique: non-responder patients, high x-ray exposure and use of iodinated contrast medium for coronary sinus angiography. This approach has not been previously described in the CHD population. We report a case of EAM-guided approach for CRT-D implantation in a young adult patient with CHD. CRT is a therapeutic option for adult patients with congenital heart disease, reduced ejection fraction and heart failure. A new implantation technique guided by electroanatomic mapping has been described to guide the left ventricular lead placement. Electroanatomic mapping could be an option to optimize CRT-D implantation in the congenital heart disease population.
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Affiliation(s)
| | - Diego Colonna
- Adult Congenital Heart Disease Unit, Department of Cardiology, Monaldi Hospital, Naples, Italy
| | - Emanuele Romeo
- Adult Congenital Heart Disease Unit, Department of Cardiology, Monaldi Hospital, Naples, Italy
| | - Berardo Sarubbi
- Adult Congenital Heart Disease Unit, Department of Cardiology, Monaldi Hospital, Naples, Italy
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8
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Xiao PL, Cai C, Zhang P, Han J, Mulpuru SK, Deshmukh AJ, Yin YH, Cha YM. Better CRT Response in Patients Who Underwent Atrioventricular Node Ablation or Upgrade From Pacemaker: A Nomogram to Predict CRT Response. Front Cardiovasc Med 2021; 8:760195. [PMID: 34790708 PMCID: PMC8591090 DOI: 10.3389/fcvm.2021.760195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 10/01/2021] [Indexed: 11/26/2022] Open
Abstract
Background: Response rates for cardiac resynchronization therapy (CRT) in patients without intrinsic left bundle-branch block (LBBB) morphology are poor. Objective: We sought to develop a nomogram model to predict response to CRT in patients without intrinsic LBBB. Methods: We searched electronic health records for patients without intrinsic LBBB who underwent CRT at Mayo Clinic. Logistic regression and Cox proportional hazards regression analysis were performed for the odds of response to CRT and risk of death, respectively. Results were used to develop the nomogram model. Results: 761 patients without intrinsic LBBB were identified. Six months after CRT, 47.8% of patients demonstrated improvement of left ventricular ejection fraction by more than 5%. The 1-, 3-, and 5-year survival rates were 95.9, 82.4, and 66.70%, respectively. Patients with CRT upgrade from pacemaker [odds ratio (OR), 1.67 (95% CI, 1.05–2.66)] or atrioventricular node (AVN) ablation [OR, 1.69 (95% CI, 1.09–2.64)] had a greater odds of CRT response than those patients who had new implant, or who did not undergo AVN ablation. Patients with right bundle-branch block had a low response rate (39.2%). Patients undergoing AVN ablation had a lower mortality rate than those without ablation [hazard ratio, 0.65 (95% CI, 0.46–0.91)]. Eight clinical variables were automatically selected to build a nomogram model and predict CRT response. The model had an area under the receiver operating characteristic curve of 0.71 (95% CI, 0.63–0.78). Conclusions: Among patients without intrinsic LBBB undergoing CRT, upgrade from pacemaker and AVN ablation were favorable factors in achieving CRT response and better long-term outcomes.
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Affiliation(s)
- Pei-Lin Xiao
- Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Cheng Cai
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Pei Zhang
- Department of Cardiology, Sir Run Run Shaw Hospital, The First Affiliated Hospital of Zhejiang University, Hangzhou, China
| | - Jie Han
- Department of Cardiology and Atrial Fibrillation Center, The First Affiliated Hospital of Zhejiang University, Hangzhou, China
| | - Siva K Mulpuru
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
| | - Abhishek J Deshmukh
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
| | - Yue-Hui Yin
- Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yong-Mei Cha
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
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9
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Yagishita D, Yagishita Y, Kataoka S, Yazaki K, Kanai M, Ejima K, Shoda M, Hagiwara N. Left Ventricular Stimulation With Electrical Latency Predicts Mortality in Patients Undergoing Cardiac Resynchronization Therapy. JACC Clin Electrophysiol 2021; 7:796-805. [PMID: 34167755 DOI: 10.1016/j.jacep.2020.10.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 09/08/2020] [Accepted: 10/27/2020] [Indexed: 11/27/2022]
Abstract
OBJECTIVES This study sought to evaluate the prognostic value of the time interval from left ventricular (LV) pacing to the earliest onset of QRS complex (S-QRS) for long-term clinical outcomes in patients who underwent cardiac resynchronization therapy (CRT). BACKGROUND The electrical latency during LV pacing evaluated by S-QRS is associated with local tissue property, and the S-QRS ≥37 ms has been previously proposed as an independent predictor of mechanical response to CRT. METHODS This study included 82 consecutive patients with heart failure with reduced LV ejection fraction (≤35%) and a wide QRS complex (≥120 ms) who underwent CRT. Patients were divided into a short S-QRS group (SS-QRS; <37 ms) and a long S-QRS group (LS-QRS; ≥37 ms). The primary endpoint was total mortality, including LV assist device implantation or heart transplantation, whereas the secondary endpoint was total mortality or HF hospitalization. RESULTS S-QRS was 25.9 ± 5.3 ms in SS-QRS and 51.5 ± 13.7 ms in LS-QRS (p < 0.01), and baseline QRS duration and electrical activation at the LV pacing site (i.e., Q-LV) were similar. During mean follow-up of 44.5 ± 21.1 months, 24 patients (29%) reached the primary endpoint, whereas the secondary endpoints were observed in 47 patients (57%). LS-QRS had significantly worse event-free survival for both endpoints. LS-QRS was an independent predictor of total mortality (hazard ratio: 2.6; 95% confidence interval: 1.11 to 6.12; p = 0.03) and the secondary composite events (hazard ratio: 2.4; 95% confidence interval: 1.31 to 4.33; p < 0.01). CONCLUSIONS The S-QRS ≥37 ms at the LV pacing site was a significant predictor of total mortality and HF hospitalization. S-QRS-guided optimal LV lead placement is critical in patients who receive CRT.
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Affiliation(s)
- Daigo Yagishita
- Department of Cardiology, Tokyo Women's Medical University, Tokyo, Japan
| | - Yoshimi Yagishita
- Department of Cardiology, Tokyo Women's Medical University, Tokyo, Japan
| | - Shohei Kataoka
- Department of Cardiology, Tokyo Women's Medical University, Tokyo, Japan
| | - Kyoichiro Yazaki
- Department of Cardiology, Tokyo Women's Medical University, Tokyo, Japan
| | - Miwa Kanai
- Department of Cardiology, Tokyo Women's Medical University, Tokyo, Japan
| | - Koichiro Ejima
- Clinical Research Division for Heart Rhythm Management, Tokyo Women's Medical University, Tokyo, Japan
| | - Morio Shoda
- Clinical Research Division for Heart Rhythm Management, Tokyo Women's Medical University, Tokyo, Japan.
| | - Nobuhisa Hagiwara
- Department of Cardiology, Tokyo Women's Medical University, Tokyo, Japan
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10
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Singh JP, Berger RD, Doshi RN, Lloyd M, Moore D, Stone J, Daoud EG. Targeted Left Ventricular Lead Implantation Strategy for Non-Left Bundle Branch Block Patients. JACC Clin Electrophysiol 2020; 6:1171-1181. [DOI: 10.1016/j.jacep.2020.04.034] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Revised: 04/20/2020] [Accepted: 04/30/2020] [Indexed: 10/23/2022]
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11
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Maines M, Peruzza F, Zorzi A, Moggio P, Angheben C, Catanzariti D, Coletti M, Pangrazzi C, Del Greco M. Coronary sinus and great cardiac vein electroanatomic mapping predicts the activation delay of the coronary sinus branches. J Cardiovasc Electrophysiol 2020; 31:2061-2067. [DOI: 10.1111/jce.14609] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Revised: 05/25/2020] [Accepted: 06/04/2020] [Indexed: 11/28/2022]
Affiliation(s)
| | - Francesco Peruzza
- Department of CardiologySanta Maria del Carmine Hospital Rovereto Italy
| | - Alessandro Zorzi
- Department of Cardiac Thoracic, Vascular Sciences, and Public HealthUniversity of Padova Padova Italy
| | - Paolo Moggio
- Department of CardiologySanta Maria del Carmine Hospital Rovereto Italy
| | - Carlo Angheben
- Department of CardiologySanta Maria del Carmine Hospital Rovereto Italy
| | | | - Marco Coletti
- Department of CardiologySanta Maria del Carmine Hospital Rovereto Italy
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12
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Lahiri A, Chahadi FK, Ganesan AN, McGavigan AD. Characteristics that Predict Response After Cardiac Resynchronization Therapy. CURRENT CARDIOVASCULAR RISK REPORTS 2020. [DOI: 10.1007/s12170-020-00640-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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13
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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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14
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The QR-max index, a novel electrocardiographic index for the determination of left ventricular conduction delay and selection of cardiac resynchronization in patients with non-left bundle branch block. J Interv Card Electrophysiol 2019; 58:147-156. [PMID: 31807986 DOI: 10.1007/s10840-019-00671-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Accepted: 11/19/2019] [Indexed: 11/26/2022]
Abstract
Non-left bundle branch block (non-LBBB) remains an uncertain indication for cardiac resynchronization therapy (CRT). Non-LBBB includes right bundle branch block (RBBB) and non-specific LV conduction delay (NSCD), two different electrocardiogram (ECG) patterns which are not generally considered to be associated with LV conduction delay as judged by the invasive assessment of the Q-LV interval. We evaluated whether a novel ECG interval (QR-max index) correlated with the degree of LV conduction delay regardless of the type of non-LBBB ECG pattern, and could, therefore, predict CRT response. In 173 non-LBBB patients on CRT (92 NSCD, 81 RBBB), the QR-max index was measured as the maximum interval from QRS onset to R-wave offset in the limb leads. The correlation between QR-max index and Q-LV interval and the impact of the QR-max index on time to first heart failure hospitalization during 3-year follow-up were assessed. Q-LV correlated better with the QR-max index than with QRSd, particularly in the RBBB group (r = 0.91; p < 0.001 vs. r = 0.19; p < 0.089), while the correlations were r = 0.79 (p < 0.01) and r = 0.68 (p < 0.01), respectively, in the NSCD group. In both groups, the QR-max index was significantly more able than QRSd to identify CRT responders (AUC 0.825 vs. 0.576; p = 0.0008 in RBBB; AUC 0.738 vs. 0.701; p = 0.459 in NSCD). A QR-max index exceeding a cutoff value of 120 ms was associated with CRT response, with predictive values of 86.8 and 81.4% in RBBB and NSCD, respectively. The QR-max index reflects the degree of LV electrical delay regardless of QRS duration in RBBB and NSCD patients and is a useful indicator of suitability for CRT in non-LBBB patients.
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15
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Friedman DJ, Emerek K, Hansen SM, Polcwiartek C, Sørensen PL, Loring Z, Sutter J, Søgaard P, Kisslo J, Graff C, Atwater BD. Non-invasively quantified changes in left ventricular activation predict outcomes in patients undergoing cardiac resynchronization therapy. J Cardiovasc Electrophysiol 2019; 30:2475-2483. [PMID: 31535746 DOI: 10.1111/jce.14192] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Revised: 08/21/2019] [Accepted: 09/09/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND Changes in left ventricular (LV) activation after cardiac resynchronization therapy (CRT) influence survival but are difficult to quantify noninvasively. METHODS AND RESULTS We studied 527 CRT patients to assess whether noninvasive quantification of changes in LV activation, defined by change (Δ) in QRS area (QRSA), can predict outcomes after CRT. The study outcome was time until LV assist device(LVAD), cardiac transplant, or death. The three-dimensional QRSA was measured from clinical 12 lead ECGs which were transformed into vectorcardiograms using the Kors method. QRSA was calculated as (QRSx2 + QRSy2 + QRSz2 )1/2 ; ΔQRSA was calculated as post-QRSA minus pre-QRSA, where a negative value represents a reduction in LV activation delay. Kaplan-Meier plots and multivariable Cox proportional hazards models were used to relate ΔQRSA area with outcomes after stratifying the population into quartiles of ΔQRSA. The median baseline QRSA of 93.6 µVs decreased to 59.7 µVs after CRT. Progressive reductions in QRSA with CRT were associated with a lower rate of LVAD, transplant, or death across patient quartiles (P < .001). In Cox regression analyses, ΔQRSA was associated with outcomes independent of QRS morphology and other clinical variables (Q1[greatest decrease] vs Q4[smallest change=reference], HR 0.45, CI, 0.30-0.70, P < .001). There was no interaction between ΔQRSA and QRS morphology. CONCLUSIONS CRT induced ΔQRSA was associated with clinically meaningful changes in event-free survival. ΔQRSA may be a novel target to guide lead implantation and device optimization.
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Affiliation(s)
- Daniel J Friedman
- Electrophysiology Section, Duke University Hospital, Durham, North Carolina.,Division of Cardiology, Duke University Hospital, Durham, North Carolina
| | - Kasper Emerek
- Division of Cardiology, Duke University Hospital, Durham, North Carolina.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Steen Møller Hansen
- Unit of Epidemiology and Biostatistics, Aalborg University Hospital, Aalborg, Denmark
| | - Christoffer Polcwiartek
- Division of Cardiology, Duke University Hospital, Durham, North Carolina.,Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
| | - Peter L Sørensen
- Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
| | - Zak Loring
- Division of Cardiology, Duke University Hospital, Durham, North Carolina
| | - Joanne Sutter
- Division of Cardiology, Duke University Hospital, Durham, North Carolina
| | - Peter Søgaard
- Unit of Epidemiology and Biostatistics, Aalborg University Hospital, Aalborg, Denmark.,Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
| | - Joseph Kisslo
- Division of Cardiology, Duke University Hospital, Durham, North Carolina
| | - Claus Graff
- Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
| | - Brett D Atwater
- Electrophysiology Section, Duke University Hospital, Durham, North Carolina.,Division of Cardiology, Duke University Hospital, Durham, North Carolina
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16
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Abstract
CRT is a cornerstone of therapy for patients with heart failure and reduced ejection fraction. By restoring left ventricular (LV) electrical and mechanical synchrony, CRT can reduce mortality, improve LV function and reduce heart failure symptoms. Since its introduction, many advances have been made that have improved the delivery of and enhanced the response to CRT. Improving CRT outcomes begins with proper patient selection so CRT is delivered to all populations that could benefit from it, and limiting the implantation of CRT in those with a small chance of response. In addition, advancements in LV leads and delivery technologies coupled with multimodality imaging and electrical mapping have enabled operators to place coronary sinus leads in locations that will optimise electrical and mechanical synchrony. Finally, new pacing strategies using LV endocardial pacing or His bundle pacing have allowed for CRT delivery and improved response in patients with poor coronary sinus anatomy or lack of response to traditional CRT.
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Affiliation(s)
- George Thomas
- Department of Medicine, Division of Cardiology, Cornell University Medical Center New York, US
| | - Jiwon Kim
- Department of Medicine, Division of Cardiology, Cornell University Medical Center New York, US
| | - Bruce B Lerman
- Department of Medicine, Division of Cardiology, Cornell University Medical Center New York, US
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17
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Dauw J, Martens P, Mullens W. CRT Optimization: What Is New? What Is Necessary? CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2019; 21:45. [PMID: 31342198 DOI: 10.1007/s11936-019-0751-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Cardiac resynchronization therapy (CRT) has proven to improve quality of life, reduce heart failure hospitalization, and prolong life in selected heart failure patients with reduced ejection fraction, on optimal medical therapy and with electrical dyssynchrony. To ensure maximal benefit for CRT patients, optimization of care should be implemented. This begins with appropriate referring as well as selecting patients, knowing that the presence of left bundle branch block and QRS ≥ 150 ms is associated with the greatest reverse remodeling. The LV lead, preferably quadripolar, is best targeted in a postero-lateral position. After implantation, optimal device programming should aim for maximal biventricular pacing and in selected cases further electrical delay optimization might be of use. Even as important, is the implementation of thorough multidisciplinary heart failure care with medication uptitration, remote monitoring, rehabilitation, and patient education. The role of newer pacing strategies as endocardial or His-bundle pacing remains the subject of ongoing investigation.
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Affiliation(s)
- Jeroen Dauw
- Department of Cardiology, Ziekenhuis Oost-Limburg, Schiepse Bos 6, 3600, Genk, Belgium
- Doctoral School for Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium
| | - Pieter Martens
- Department of Cardiology, Ziekenhuis Oost-Limburg, Schiepse Bos 6, 3600, Genk, Belgium
- Doctoral School for Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium
| | - Wilfried Mullens
- Department of Cardiology, Ziekenhuis Oost-Limburg, Schiepse Bos 6, 3600, Genk, Belgium.
- Biomedical Research Institute, Faculty of Medicine and Life Sciences, LCRC, Hasselt University, Diepenbeek, Belgium.
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18
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Time interval from left ventricular stimulation to QRS onset is a novel predictor of nonresponse to cardiac resynchronization therapy. Heart Rhythm 2019; 16:395-402. [DOI: 10.1016/j.hrthm.2018.08.035] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Indexed: 11/23/2022]
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19
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Nguyên UC, Cluitmans MJM, Strik M, Luermans JG, Gommers S, Wildberger JE, Bekkers SCAM, Volders PGA, Mihl C, Prinzen FW, Vernooy K. Integration of cardiac magnetic resonance imaging, electrocardiographic imaging, and coronary venous computed tomography angiography for guidance of left ventricular lead positioning. Europace 2018; 21:626-635. [DOI: 10.1093/europace/euy292] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Accepted: 11/12/2018] [Indexed: 11/13/2022] Open
Affiliation(s)
- Uyên Châu Nguyên
- Department of Physiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, the Netherlands
- Department of Cardiology, CARIM, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Matthijs J M Cluitmans
- Department of Cardiology, CARIM, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Marc Strik
- Department of Cardiology, CARIM, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Justin G Luermans
- Department of Cardiology, CARIM, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Suzanne Gommers
- Department of Radiology, CARIM, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Joachim E Wildberger
- Department of Radiology, CARIM, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Sebastiaan C A M Bekkers
- Department of Physiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, the Netherlands
- Department of Radiology, CARIM, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Paul G A Volders
- Department of Cardiology, CARIM, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Casper Mihl
- Department of Radiology, CARIM, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Frits W Prinzen
- Department of Physiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, the Netherlands
| | - Kevin Vernooy
- Department of Cardiology, CARIM, Maastricht University Medical Center, Maastricht, the Netherlands
- Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands
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20
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Elsaid O, Gulati V, Tecson K, Friedman M, Kluger J. Ventricular electrical delay as a predictor of arrhythmias in patients with cardiac resynchronization implantable cardioverter defibrillator. SCAND CARDIOVASC J 2018; 52:356-361. [PMID: 30570402 DOI: 10.1080/14017431.2018.1562202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND Left ventricular (LV) remodeling and clinical response to cardiac resynchronization therapy (CRT) is inversely related to electrical dyssynchrony, measured as LV lead electrical delay (QLV). Presence of atrial or ventricular arrhythmia is correlated with worsening heart failure and LV remodeling. OBJECTIVE We sought to assess the association of QLV with arrhythmic events in CRT recipients. METHODS We identified patients implanted with a CRT device at our center. QLV interval was measured and corrected for baseline QRS (cQLV). We performed multivariable Logistic regression to assess the effect of cQLV on the occurrence of atrial/ventricular arrhythmic events. RESULTS Sixty-nine patients were included in analyses. The cQLV was significantly shorter in patients with atria tachycardia/supraventricular tachycardia (AT/SVT) events compared to patients without AT/SVT events (43.4 ± 22% vs. 60.3 ± 26.7%, p = .006). In contrast, no significant difference in cQLV was observed between patients with and without ventricular tachycardia/fibrillation (VT/VF) events (46.2 ± 25.4% vs. 56 ± 25.7%, p = .13). cQLV was significantly shorter in patients with new onset AT/SVT events compared to those without (38.3 ± 22.2% vs. 55.7 ± 25.7%, p = .028). In contrast, no significant difference in cQLV was observed between patients with and without new onset VT/VF events (44.2 ± 25.2% vs. 56.3 ± 25.5%, p = .069). Following adjusted analyses, cQLV was a significant predictor of AT/SVT, but not for VT/VF. CONCLUSION cQLV is a simple measure that can identify a vulnerable cohort of CRT patients at increased risk for atrial tachyarrhythmias, and hence can predict reverse remodeling and clinical response to CRT treatment.
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Affiliation(s)
- Ossama Elsaid
- a Henry Low Heart Center , Hartford Hospital , Hartford , CT , USA.,b Cardiology Division , Baylor University Medical Center , Dallas , TX , USA
| | - Vinay Gulati
- a Henry Low Heart Center , Hartford Hospital , Hartford , CT , USA
| | - Kristen Tecson
- b Cardiology Division , Baylor University Medical Center , Dallas , TX , USA
| | - Meir Friedman
- a Henry Low Heart Center , Hartford Hospital , Hartford , CT , USA
| | - Jeffrey Kluger
- a Henry Low Heart Center , Hartford Hospital , Hartford , CT , USA
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21
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Stephansen C, Sommer A, Kronborg MB, Jensen JM, Bouchelouche K, Nielsen JC. Electrically guided versus imaging-guided implant of the left ventricular lead in cardiac resynchronization therapy: a study protocol for a double-blinded randomized controlled clinical trial (ElectroCRT). Trials 2018; 19:600. [PMID: 30382923 PMCID: PMC6211399 DOI: 10.1186/s13063-018-2930-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Accepted: 09/24/2018] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND Cardiac resynchronization therapy (CRT) is an established treatment in patients with heart failure and prolonged QRS duration where a biventricular pacemaker is implanted to achieve faster activation and more synchronous contraction of the left ventricle (LV). Despite the convincing effect of CRT, 30-40% of patients do not respond. Among the most important correctable causes of non-response to CRT is non-optimal LV lead position. METHODS We will enroll 122 patients in this patient-blinded and assessor-blinded, randomized, clinical trial aiming to investigate if implanting the LV lead guided by electrical mapping towards the latest LV activation as compared with imaging-guided implantation, causes an excess increase in left ventricular (LV) ejection fraction (LVEF). The patients are randomly assigned to either the intervention group: preceded by cardiac computed tomography of the cardiac venous anatomy, the LV lead is placed according to the latest LV activation in the coronary sinus (CS) branches identified by systematic electrical mapping of the CS at implantation and post-implant optimization of the interventricular pacing delay; or patients are assigned to the control group: placement of the LV lead guided by cardiac imaging. The LV lead is targeted towards the latest mechanical LV activation as identified by echocardiography and outside myocardial scar as identified by myocardial perfusion (MP) imaging. The primary endpoint is change in LVEF at 6-month follow up (6MFU) as compared with baseline measured by two-dimensional echocardiography. Secondary endpoints include relative percentage reduction in LV end-systolic volume, all-cause mortality, hospitalization for heart failure, and a clinical combined endpoint of response to CRT at 6MFU defined as the patient being alive, not hospitalized for heart failure, and experiencing improvement in NYHA functional class or/and > 10% increase in 6-minute walk test. DISCUSSION We assume an absolute increase in LVEF of 12% in the intervention group versus 8% in the control group. If an excess increase in LVEF can be achieved by LV lead implantation guided by electrical mapping, this study supports the conduct of larger trials investigating the impact of this strategy for LV-lead implantation on clinical outcomes in patients treated with CRT. TRIAL REGISTRATION ClinicalTrials.gov, NCT02346097 . Registered on 12 January 2015. Patients were enrolled between 16 February 2015 and 13 December 2017.
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Affiliation(s)
- Charlotte Stephansen
- Department of Cardiology – Research, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, DK-8200 Aarhus N, Denmark
| | - Anders Sommer
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, DK-8200 Aarhus N, Denmark
| | - Mads Brix Kronborg
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, DK-8200 Aarhus N, Denmark
| | - Jesper Møller Jensen
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, DK-8200 Aarhus N, Denmark
| | - Kirsten Bouchelouche
- Department of Nuclear Medicine, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, DK-8200 Aarhus N, Denmark
| | - Jens Cosedis Nielsen
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, DK-8200 Aarhus N, Denmark
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22
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Singh JP, Berger RD, Doshi RN, Lloyd M, Moore D, Daoud EG. Rationale and design for ENHANCE CRT: QLV implant strategy for non-left bundle branch block patients. ESC Heart Fail 2018; 5:1184-1190. [PMID: 30264456 PMCID: PMC6300807 DOI: 10.1002/ehf2.12340] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Revised: 05/31/2018] [Accepted: 06/22/2018] [Indexed: 11/10/2022] Open
Abstract
AIMS Historically, cardiac resynchronization therapy (CRT) response in non-left bundle branch block (non-LBBB) patients has been suboptimal in comparison with that observed in left bundle branch block patients. The electrical activation pattern of the left ventricle (LV) is different between these two QRS morphologies. Small non-randomized studies have suggested that targeting the LV wall with greatest electrical delay may be superior to conventional anatomical pacing from the lateral wall in non-LBBB patients. This article outlines the design and rationale of a prospective, randomized, pilot study, which assesses the effect of a non-traditional LV lead implant strategy on the clinical composite score after 12 months of follow-up in a non-LBBB patient population. METHODS All patients will receive an Abbott quadripolar CRT-D system (Quartet 1458Q LV lead with Unify Quadra™, Quadra Assura™ CRT-D or any market-approved CRT-D device with quadripolar pacing capabilities). Patients will be randomized in a 2:1 ratio between a QLV-based implant strategy vs. standard of care. Up to 250 patients will be enrolled in the study. CONCLUSIONS If the primary endpoint is achieved, this study will provide important information about reducing the non-responder rate in non-LBBB patients and provide further evidence for the QLV-based implant strategy.
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Affiliation(s)
| | | | - Rahul N Doshi
- University of Southern California, Los Angeles, CA, USA
| | | | - Douglas Moore
- St John Hospital and Medical Center, Detroit, MI, USA
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- The Ohio State University, Columbus, OH, USA
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23
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Müller-Leisse J, Zormpas C, König T, Duncker D, Veltmann C. [Multipoint pacing-more CRT or a waste of battery power?]. Herz 2018; 43:596-604. [PMID: 30209518 DOI: 10.1007/s00059-018-4751-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Cardiac resynchronization therapy (CRT) reduces morbidity and mortality in patients with broad QRS complex ≥130 ms and heart failure with reduced ejection fraction despite optimal guideline-directed medical therapy. However, approximately 30% of the patients implanted with a CRT system do not show clinical benefit. Reasons for nonresponse are complex and some aspects can be addressed during follow-up. Based on quadripolar lead technology, multipoint pacing (MPP) allows left ventricular stimulation at two different sites along the lead. In particular, in scarred and fibrotic ventricular myocardium stimulation at two different sites may overcome conduction barriers and lead to homogeneous ventricular depolarization. Especially for patients that do not respond to conventional CRT, activation of MPP may present an option to increase clinical response. On the other hand, MPP may significantly decrease battery longevity.This review offers an overview of the current knowledge and data on MPP balancing the potential clinical benefit and the possible disadvantages of this therapy.
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Affiliation(s)
- J Müller-Leisse
- Rhythmologie und Elektrophysiologie, Klinik für Kardiologie und Angiologie, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625, Hannover, Deutschland
| | - C Zormpas
- Rhythmologie und Elektrophysiologie, Klinik für Kardiologie und Angiologie, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625, Hannover, Deutschland
| | - T König
- Rhythmologie und Elektrophysiologie, Klinik für Kardiologie und Angiologie, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625, Hannover, Deutschland
| | - D Duncker
- Rhythmologie und Elektrophysiologie, Klinik für Kardiologie und Angiologie, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625, Hannover, Deutschland
| | - C Veltmann
- Rhythmologie und Elektrophysiologie, Klinik für Kardiologie und Angiologie, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625, Hannover, Deutschland.
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24
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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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25
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Rahsepar AA, Collins JD, Knight BP, Hong K, Carr JC, Kim D. Wideband LGE MRI permits unobstructed viewing of myocardial scarring in a patient with an MR-conditional subcutaneous implantable cardioverter-defibrillator. Clin Imaging 2018; 50:294-296. [PMID: 29747127 DOI: 10.1016/j.clinimag.2018.05.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Revised: 04/24/2018] [Accepted: 05/01/2018] [Indexed: 10/17/2022]
Abstract
A subcutaneous implantable cardioverter-defibrillator (S-ICD) is an alternative device for prevention of sudden cardiac death, without any leads within the heart. Patients implanted with any type of ICD may need catheter ablation of ventricular tachycardia (VT) to reduce the overall arrhythmia burden (e.g., recurrent monomorphic VT) and lower the incidence of painful shocks induced by the device. Late gadolinium enhancement (LGE) MRI is a useful pre-test for guiding VT ablation, because it can be used to map myocardial scar and produce better outcomes. Growing evidence suggests that MRI can be performed with manageable risks on patients with a cardiac implantable electronic device (CIED). Nonetheless, the diagnostic yield of cardiac MRI is still low because of severe image artifacts, regardless of MR-conditional or non-MR conditional labeling. Image artifacts in the heart induced by an S-ICD is expected to be larger than the artifacts induced by a transvenous ICD, because the former is twice as large in size and implanted closer to the heart. This is the first reported case of successful wideband LGE MRI in a patient implanted with an MR-conditional S-ICD. A 37-year-old man with ischemic cardiomyopathy was referred for a cardiac MRI at 1.5 T ten months after S-ICD implantation, in order to rule out constrictive pericarditis. Clinical standard LGE MRI produced severe image artifacts, rendering it useless. In contrast, wideband LGE MRI provided unobstructed viewing of myocardial scarring. This case illustrates the usefulness of wideband LGE MRI for assessment of myocardial scarring in a patient with an MR-conditional S-ICD.
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Affiliation(s)
- Amir Ali Rahsepar
- Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Jeremy D Collins
- Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Bradley P Knight
- Department of Medicine, Division of Cardiology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - KyungPyo Hong
- Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - James C Carr
- Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Daniel Kim
- Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA.
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Daubert C, Behar N, Martins RP, Mabo P, Leclercq C. Avoiding non-responders to cardiac resynchronization therapy: a practical guide. Eur Heart J 2018; 38:1463-1472. [PMID: 27371720 DOI: 10.1093/eurheartj/ehw270] [Citation(s) in RCA: 91] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2016] [Accepted: 06/02/2016] [Indexed: 01/14/2023] Open
Abstract
Over two decades after the introduction of cardiac resynchronization therapy (CRT) into clinical practice, ∼30% of candidates continue to fail to respond to this highly effective treatment of drug-refractory heart failure (HF). Since the causes of this non-response (NR) are multifactorial, it will require multidisciplinary efforts to overcome. Progress has, thus far, been slowed by several factors, ranging from a lack of consensus regarding the definition of NR and technological limitations to the delivery of therapy. We critically review the various endpoints that have been used in landmark clinical trials of CRT, and the variability in response rates that has been observed as a result of these different investigational designs, different sample populations enrolled and different means of therapy delivered, including new means of multisite and left ventricular endocardial simulation. Precise recommendations are offered regarding the optimal device programming, use of telemonitoring and optimization of management of HF. Potentially reversible causes of NR to CRT are reviewed, with emphasis on loss of biventricular stimulation due to competing arrhythmias. The prevention of NR to CRT is essential to improve the overall performance of this treatment and lower its risk-benefit ratio. These objectives require collaborative efforts by the HF team, the electrophysiologists and the cardiac imaging experts.
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Affiliation(s)
- Claude Daubert
- School of medicine, Rennes 1 University, Rennes, France.,LTSI INSERM U1099, Rennes, France
| | - Nathalie Behar
- Cardiology and vascular diseases Division, Rennes University Hospital, Rennes, France
| | - Raphaël P Martins
- School of medicine, Rennes 1 University, Rennes, France.,LTSI INSERM U1099, Rennes, France.,Cardiology and vascular diseases Division, Rennes University Hospital, Rennes, France
| | - Philippe Mabo
- School of medicine, Rennes 1 University, Rennes, France.,LTSI INSERM U1099, Rennes, France.,Cardiology and vascular diseases Division, Rennes University Hospital, Rennes, France
| | - Christophe Leclercq
- School of medicine, Rennes 1 University, Rennes, France.,LTSI INSERM U1099, Rennes, France.,Cardiology and vascular diseases Division, Rennes University Hospital, Rennes, France
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Gazzoni GF, Fraga MB, Ferrari ADL, Soliz PDC, Borges AP, Bartholomay E, Kalil CAA, Giaretta V, Rohde LEP. Predictors of Total Mortality and Echocardiographic Response for Cardiac Resynchronization Therapy: A Cohort Study. Arq Bras Cardiol 2017; 109:569-578. [PMID: 29185615 PMCID: PMC5783438 DOI: 10.5935/abc.20170171] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Accepted: 08/09/2017] [Indexed: 01/02/2023] Open
Abstract
Background Clinical studies demonstrate that up to 40% of patients do not respond to
cardiac resynchronization therapy (CRT), thus, appropriate patient selection
is critical to the success of CRT in heart failure. Objective Evaluation of mortality predictors and response to CRT in the Brazilian
scenario. Methods Retrospective cohort study including patients submitted to CRT in a tertiary
hospital in southern Brazil from 2008 to 2014. Survival was assessed through
a database of the State Department of Health (RS). Predictors of
echocardiographic response were evaluated using Poisson regression. Survival
analysis was performed by Cox regression and Kaplan Meyer curves. A
two-tailed p value less than 0.05 was considered statistically
significant. Results A total of 170 patients with an average follow-up of 1011 ± 632 days
were included. The total mortality was 30%. The independent predictors of
mortality were age (hazard ratio [HR] of 1.05, p = 0.027), previous acute
myocardial infarction (AMI) (HR of 2.17, p = 0.049) and chronic obstructive
pulmonary disease (COPD) (HR of 3.13, p = 0.015). The percentage of
biventricular stimulation at 6 months was identified as protective factor of
mortality ([HR] 0.97, p = 0.048). The independent predictors associated with
the echocardiographic response were absence of mitral insufficiency,
presence of left bundle branch block and percentage of biventricular
stimulation. Conclusion Mortality in patients submitted to CRT in a tertiary hospital was
independently associated with age, presence of COPD and previous AMI. The
percentage of biventricular pacing evaluated 6 months after resynchronizer
implantation was independently associated with improved survival and
echocardiographic response.
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Affiliation(s)
- Guilherme Ferreira Gazzoni
- Hospital São Lucas da Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS) Porto Alegre, RS - Brazil.,Programa de Pós-Graduação em Cardiologia e Ciências Cardiovasculares da Faculdade de Medicina da Universidade Federal do Rio Grande do Sul, Porto Alegre, RS - Brazil
| | - Matheus Bom Fraga
- Hospital São Lucas da Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS) Porto Alegre, RS - Brazil
| | - Andres Di Leoni Ferrari
- Hospital São Lucas da Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS) Porto Alegre, RS - Brazil
| | - Pablo da Costa Soliz
- Hospital São Lucas da Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS) Porto Alegre, RS - Brazil
| | - Anibal Pires Borges
- Hospital São Lucas da Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS) Porto Alegre, RS - Brazil
| | - Eduardo Bartholomay
- Hospital São Lucas da Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS) Porto Alegre, RS - Brazil
| | | | - Vanessa Giaretta
- Programa de Pós-Graduação em Cardiologia e Ciências Cardiovasculares da Faculdade de Medicina da Universidade Federal do Rio Grande do Sul, Porto Alegre, RS - Brazil
| | - Luis Eduardo Paim Rohde
- Programa de Pós-Graduação em Cardiologia e Ciências Cardiovasculares da Faculdade de Medicina da Universidade Federal do Rio Grande do Sul, Porto Alegre, RS - Brazil
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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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Nguyên UC, Prinzen FW, Vernooy K. Left ventricular lead positioning in cardiac resynchronization therapy: Mission accomplished? Heart Rhythm 2017; 14:1373-1374. [DOI: 10.1016/j.hrthm.2017.05.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Indexed: 10/19/2022]
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Chatterjee NA, Gold MR, Waggoner AD, Picard MH, Stein KM, Yu Y, Meyer TE, Wold N, Ellenbogen KA, Singh JP. Longer Left Ventricular Electric Delay Reduces Mitral Regurgitation After Cardiac Resynchronization Therapy: Mechanistic Insights From the SMART-AV Study (SmartDelay Determined AV Optimization: A Comparison to Other AV Delay Methods Used in Cardiac Resynchronization Therapy). Circ Arrhythm Electrophysiol 2017; 9:CIRCEP.116.004346. [PMID: 27906653 DOI: 10.1161/circep.116.004346] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2016] [Accepted: 10/05/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND Mitral regurgitation (MR) is associated with worse survival in those undergoing cardiac resynchronization therapy (CRT). Left ventricular (LV) lead position in CRT may ameliorate mechanisms of MR. We examine the association between a longer LV electric delay (QLV) at the LV stimulation site and MR reduction after CRT. METHODS AND RESULTS QLV was assessed retrospectively in 426 patients enrolled in the SMART-AV study (SmartDelay Determined AV Optimization: A Comparison to Other AV Delay Methods Used in CRT). QLV was defined as the time from QRS onset to the first large peak of the LV electrogram. Linear regression and logistic regression were used to assess the association between baseline QLV and MR reduction at 6 months (absolute change in vena contracta width and odds of ≥1 grade reduction in MR). At baseline, there was no difference in MR grade, LV dyssynchrony, or LV volumes in those with QLV above versus below the median (95 ms). After multivariable adjustment, increasing QLV was an independent predictor of MR reduction at 6 months as reflected by an increased odds of MR response (odds ratio: 1.13 [1.03-1.25]/10 ms increase QLV; P=0.02) and a decrease in vena contracta width (P<0.001). At 3 months, longer QLV (≥median) was associated with significant decrease in LV end-systolic volume (ΔLV end-systolic volume -28.2±38.9 versus -4.9±33.8 mL, P<0.001). Adjustment for 3-month ΔLV end-systolic volume attenuated the association between QLV and 6-month MR reduction. CONCLUSIONS In patients undergoing CRT, longer QLV was an independent predictor of MR reduction at 6 months and associated with interval 3-month LV reverse remodeling. These findings provide a mechanistic basis for using an electric-targeting LV lead strategy at the time of CRT implant.
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Affiliation(s)
| | | | | | | | | | - Yinghong Yu
- For the author affiliations, please see the Appendix
| | | | - Nicholas Wold
- For the author affiliations, please see the Appendix
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DEL GRECO MAURIZIO, MAINES MASSIMILIANO, MARINI MASSIMILIANO, COLELLA ANDREA, ZECCHIN MASSIMO, VITALI-SERDOZ LAURA, BLANDINO ALESSANDRO, BARBONAGLIA LORELLA, ALLOCCA GIUSEPPE, MUREDDU ROBERTO, MARENNA BIONDINO, ROSSI PAOLO, VACCARI DIEGO, CHIANCA ROBERTO, INDIANI STEFANO, DI MATTEO IRENE, ANGHEBEN CARLO, ZORZI ALESSANDRO. Three-Dimensional Electroanatomic Mapping System-Enhanced Cardiac Resynchronization Therapy Device Implantation: Results From a Multicenter Registry. J Cardiovasc Electrophysiol 2016; 28:85-93. [DOI: 10.1111/jce.13120] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2016] [Revised: 09/18/2016] [Accepted: 10/10/2016] [Indexed: 11/28/2022]
Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - ALESSANDRO ZORZI
- Santa Maria del Carmine Hospital; Rovereto Italy
- Department of Cardiac, Thoracic and Vascular Sciences; University of Padova; Padova Italy
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Del Greco M, Zorzi A, Di Matteo I, Cima A, Maines M, Angheben C, Catanzariti D. Coronary sinus activation patterns in patients with and without left bundle branch block undergoing electroanatomic mapping system-guided cardiac resynchronization therapy device implantation. Heart Rhythm 2016; 14:225-233. [PMID: 27989791 DOI: 10.1016/j.hrthm.2016.10.025] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2016] [Indexed: 11/17/2022]
Abstract
BACKGROUND Implantation of the left ventricular (LV) lead in segments with delayed electrical activation may improve response to cardiac resynchronization therapy (CRT). OBJECTIVE The purpose of this study was to evaluate the amount and regional distribution of LV electrical delay (LVED) in patients with or without left bundle branch block (LBBB). METHODS We enrolled 60 patients who underwent electroanatomic mapping system-guided CRT device implantation. Activation mapping of the coronary sinus (CS) branches was performed using an insulated guidewire. LVED was defined as the interval between the beginning of the QRS complex on the surface electrocardiogram (ECG) and the local electrogram and expressed in milliseconds or as percentage of the total QRS duration (LVED%). RESULTS Forty-three patients showed a LBBB and 17 a non-LBBB electrocardiographic pattern. A total of 148 CS branches (mean 2.5 per patient; range 2-4 per patient) were mapped. Patients with LBBB showed higher maximum LVED (135 ms [108-150 ms] vs 100 ms [103-110 ms]; P < .001) and LVED% (86% [79%-89%] vs 72% [54%-80%]; P < .001) than did patients without LBBB. The maximum LVED was recorded in mid-basal anterolateral or inferolateral LV segments (traditional CRT targets), significantly more often in patients with LBBB than in patients without LBBB (85% vs 59%; P = .02). The number of CS branches showing LVED >50% of the total QRS duration, >75% of the total QRS duration, and >85 ms was significantly higher in patients with LBBB than in patients without LBBB. CONCLUSION Patients without LBBB showed lower LVED and more heterogeneous electrical activation of the CS than did patients with LBBB. This finding may contribute to a lower rate of response to CRT of patients without LBBB and suggests the use of activation mapping to guide LV lead placement.
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Affiliation(s)
| | - Alessandro Zorzi
- Santa Maria del Carmine Hospital, Rovereto TN, Italy,; Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Padova, Italy
| | | | - Anna Cima
- Santa Maria del Carmine Hospital, Rovereto TN, Italy
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Nguyên UC, Mafi-Rad M, Aben JP, Smulders MW, Engels EB, van Stipdonk AMW, Luermans JGLM, Bekkers SCAM, Prinzen FW, Vernooy K. A novel approach for left ventricular lead placement in cardiac resynchronization therapy: Intraprocedural integration of coronary venous electroanatomic mapping with delayed enhancement cardiac magnetic resonance imaging. Heart Rhythm 2016; 14:110-119. [PMID: 27663606 DOI: 10.1016/j.hrthm.2016.09.015] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Indexed: 12/21/2022]
Abstract
BACKGROUND Placing the left ventricular (LV) lead at a site of late electrical activation remote from scar is desired to improve cardiac resynchronization therapy (CRT) response. OBJECTIVE The purpose of this study was to integrate coronary venous electroanatomic mapping (EAM) with delayed enhancement cardiac magnetic resonance (DE-CMR) enabling LV lead guidance to the latest activated vein remote from scar. METHODS Eighteen CRT candidates with focal scar on DE-CMR were prospectively included. DE-CMR images were semi-automatically analyzed. Coronary venous EAM was performed intraprocedurally and integrated with DE-CMR to guide LV lead placement in real time. Image integration accuracy and electrogram parameters were evaluated offline. RESULTS Integration of EAM and DE-CMR was achieved using 8.9 ± 2.8 anatomic landmarks and with accuracy of 4.7 ± 1.1 mm (mean ± SD). Maximal electrical delay ranged between 72 and 197ms (57%-113% of QRS duration) and was heterogeneously located among individuals. In 12 patients, the latest activated vein was located outside scar, and placing the LV lead in the latest activated vein remote from scar was accomplished in 10 patients and prohibited in 2 patients. In the other 6 patients, the latest activated vein was located in scar, and targeting alternative veins was considered. Unipolar voltages were on average lower in scar compared to nonscar (6.71 ± 3.45 mV vs 8.18 ± 4.02 mV [median ± interquartile range), P <.001) but correlated weakly with DE-CMR scar extent (R -0.161, P <.001) and varied widely among individual patients. CONCLUSION Integration of coronary venous EAM with DE-CMR can be used during CRT implantation to guide LV lead placement to the latest activated vein remote from scar, possibly improving CRT.
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Affiliation(s)
- Uyên Châu Nguyên
- Department of Physiology, Cardiovascular Research Institute Maastricht, Maastricht, the Netherlands.
| | - Masih Mafi-Rad
- Department of Cardiology, Maastricht University Medical Center, Maastricht, the Netherlands
| | | | - Martijn W Smulders
- Department of Cardiology, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Elien B Engels
- Department of Physiology, Cardiovascular Research Institute Maastricht, Maastricht, the Netherlands
| | | | - Justin G L M Luermans
- Department of Cardiology, Maastricht University Medical Center, Maastricht, the Netherlands
| | | | - Frits W Prinzen
- Department of Physiology, Cardiovascular Research Institute Maastricht, Maastricht, the Netherlands
| | - Kevin Vernooy
- Department of Cardiology, Maastricht University Medical Center, Maastricht, the Netherlands
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Sommer A, Kronborg MB, Nørgaard BL, Poulsen SH, Bouchelouche K, Böttcher M, Jensen HK, Jensen JM, Kristensen J, Gerdes C, Mortensen PT, Nielsen JC. Multimodality imaging-guided left ventricular lead placement in cardiac resynchronization therapy: a randomized controlled trial. Eur J Heart Fail 2016; 18:1365-1374. [PMID: 27087019 DOI: 10.1002/ejhf.530] [Citation(s) in RCA: 92] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2015] [Revised: 02/25/2016] [Accepted: 03/03/2016] [Indexed: 12/13/2022] Open
Abstract
AIM Left ventricular (LV) lead position at the latest mechanically activated non-scarred myocardial LV region confers improved response to cardiac resynchronization therapy (CRT). We conducted a double-blind, randomized controlled trial to evaluate the clinical benefit of multimodality imaging-guided LV lead placement in CRT. METHODS AND RESULTS Patients were allocated (1:1) to imaging-guided LV lead placement using cardiac computed tomography (CT) venography, 99m Technetium myocardial perfusion imaging, and speckle-tracking echocardiography radial strain to target the optimal coronary sinus (CS) branch closest to the non-scarred myocardial segment with latest mechanical activation (imaging group, n = 89) or to routine LV lead implantation in a posterolateral region with late electrical activation (control group, n = 93). The primary endpoint was clinical non-response to CRT [≥1 of the following after 6 months: (1) death, (2) heart failure hospitalization, or (3) no improvement in New York Heart Association class and <10% increase in 6-min walk distance]. Secondary outcomes included LV remodelling and the combination of all-cause mortality and hospitalization owing to heart failure during 1.8 ± 0.9 years. Analysis was intention-to-treat. In the imaging group, fewer patients reached the primary endpoint (26% vs. 42%, P = 0.02). More patients in the imaging group had the LV lead placed in the optimal CS branch (83% vs. 65%, P = 0.01). There were no between-group differences in reverse LV remodelling or the combined endpoint of death or hospitalizations for heart failure. CONCLUSIONS Multimodality imaging-guided LV lead placement towards the CS branch closest to latest mechanically activated non-scarred myocardial LV segment reduces the proportion of clinical non-responders to CRT. Larger long-term multicentre studies are needed.
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Affiliation(s)
- Anders Sommer
- Department of Cardiology, Aarhus University Hospital, Skejby, Palle Juul-Jensens Boulevard 99, DK-8200, Aarhus N, Denmark.
| | - Mads Brix Kronborg
- Department of Cardiology, Aarhus University Hospital, Skejby, Palle Juul-Jensens Boulevard 99, DK-8200, Aarhus N, Denmark
| | - Bjarne Linde Nørgaard
- Department of Cardiology, Aarhus University Hospital, Skejby, Palle Juul-Jensens Boulevard 99, DK-8200, Aarhus N, Denmark
| | - Steen Hvitfeldt Poulsen
- Department of Cardiology, Aarhus University Hospital, Skejby, Palle Juul-Jensens Boulevard 99, DK-8200, Aarhus N, Denmark
| | - Kirsten Bouchelouche
- Department of Nuclear Medicine, Aarhus University Hospital, Skejby, Aarhus N, Denmark
| | - Morten Böttcher
- Department of Cardiology, Herning Hospital, Herning, Denmark
| | - Henrik Kjaerulf Jensen
- Department of Cardiology, Aarhus University Hospital, Skejby, Palle Juul-Jensens Boulevard 99, DK-8200, Aarhus N, Denmark
| | - Jesper Møller Jensen
- Department of Cardiology, Aarhus University Hospital, Skejby, Palle Juul-Jensens Boulevard 99, DK-8200, Aarhus N, Denmark
| | - Jens Kristensen
- Department of Cardiology, Aarhus University Hospital, Skejby, Palle Juul-Jensens Boulevard 99, DK-8200, Aarhus N, Denmark
| | - Christian Gerdes
- Department of Cardiology, Aarhus University Hospital, Skejby, Palle Juul-Jensens Boulevard 99, DK-8200, Aarhus N, Denmark
| | - Peter Thomas Mortensen
- Department of Cardiology, Aarhus University Hospital, Skejby, Palle Juul-Jensens Boulevard 99, DK-8200, Aarhus N, Denmark
| | - Jens Cosedis Nielsen
- Department of Cardiology, Aarhus University Hospital, Skejby, Palle Juul-Jensens Boulevard 99, DK-8200, Aarhus N, Denmark
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Hara H, Niwano S, Ito H, Karakawa M, Ako J. Evaluation of R-wave offset in the left chest leads for estimating the left ventricular activation delay: An evaluation based on coronary sinus electrograms and the 12-lead electrocardiogram. J Electrocardiol 2016; 49:148-53. [PMID: 26763306 DOI: 10.1016/j.jelectrocard.2015.12.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND The QRS duration does not always reflect the left ventricular (LV) activation delay in patients with ventricular conduction disturbances. The R-wave offset in left chest leads may more closely reflect the LV activation delay than the QRS offset. METHODS We evaluated 138 cases with left bundle branch block (LBBB, n=11), right BBB (RBBB, n=38), non-specific intraventricular conduction disturbance (n=11), narrow QRS (<120ms, n=56) and right ventricular pacing (n=22). Cases with right axis deviation (120 to 270 degrees) were excluded. The intervals from the QRS onset to the V-waves in coronary sinus bipolar electrograms (QCS) were measured, and the longest interval was defined as the QCSmax. In the 12-lead electrocardiogram, the interval from the QRS onset to the R-wave offset (QR) was measured and then averaged in leads I-aVL, II-III-aVF, V1-V2, V3-V4 and V5-V6. RESULTS Significant correlations (p<0.05) were found between QCSmax and QR in I-aVL (r=0.83), II-III-aVF (r=0.51) and V5-V6 (r=0.86) in cases with a normal axis (0 to 90 degrees, n=64); and I-aVL (r=0.90), II-III-aVF (r=0.31) and V5-V6 (r=0.69) in cases with left axis deviation (-45 to -89 degrees, n=52). Overall, the QRS duration was also correlated with QCSmax (r=0.72, p<0.001); however, this correlation was weaker than the correlation between QCSmax and QR in I-aVL (r=0.89, p<0.001) due to disparities in RBBB (p<0.001). CONCLUSIONS The interval from the QRS onset to R-wave offset in the left chest leads reflects the degree of LV activation delay regardless of differences in QRS duration and morphology.
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Affiliation(s)
- Hideyuki Hara
- Cardiology, Numazu City Hospital, Shizuoka, Japan; Department of Cardiovascular Medicine, Kitasato University School of Medicine, Kanagawa, Japan.
| | - Shinichi Niwano
- Department of Cardiovascular Medicine, Kitasato University School of Medicine, Kanagawa, Japan
| | - Hiroshi Ito
- Cardiology, Numazu City Hospital, Shizuoka, Japan
| | | | - Junya Ako
- Department of Cardiovascular Medicine, Kitasato University School of Medicine, Kanagawa, Japan
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Biton Y, Baman JR, Polonsky B. Roles and indications for use of implantable defibrillator and resynchronization therapy in the prevention of sudden cardiac death in heart failure. Heart Fail Rev 2016; 21:433-46. [DOI: 10.1007/s10741-016-9542-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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Biton Y, Kutyifa V, Cygankiewicz I, Goldenberg I, Klein H, McNitt S, Polonsky B, Ruwald AC, Ruwald MH, Moss AJ, Zareba W. Relation of QRS Duration to Clinical Benefit of Cardiac Resynchronization Therapy in Mild Heart Failure Patients Without Left Bundle Branch Block. Circ Heart Fail 2016; 9:e002667. [DOI: 10.1161/circheartfailure.115.002667] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Yitschak Biton
- From the Heart Research Follow-up Program, Division of Cardiology, Department of Medicine at the University of Rochester Medical Center, NY (Y.B., V.K., I.C., I.G., H.K., S.M., B.P., A.C.R., M.H.R., A.J.M., W.Z.); Department of Cardiology, Gentofte University Hospital, Copenhagen, Denmark (A.C.R., M.H.R.); and Heart Institute, Sheba Medical Center, Ramat Gan, and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel (Y.B., I.G.)
| | - Valentina Kutyifa
- From the Heart Research Follow-up Program, Division of Cardiology, Department of Medicine at the University of Rochester Medical Center, NY (Y.B., V.K., I.C., I.G., H.K., S.M., B.P., A.C.R., M.H.R., A.J.M., W.Z.); Department of Cardiology, Gentofte University Hospital, Copenhagen, Denmark (A.C.R., M.H.R.); and Heart Institute, Sheba Medical Center, Ramat Gan, and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel (Y.B., I.G.)
| | - Iwona Cygankiewicz
- From the Heart Research Follow-up Program, Division of Cardiology, Department of Medicine at the University of Rochester Medical Center, NY (Y.B., V.K., I.C., I.G., H.K., S.M., B.P., A.C.R., M.H.R., A.J.M., W.Z.); Department of Cardiology, Gentofte University Hospital, Copenhagen, Denmark (A.C.R., M.H.R.); and Heart Institute, Sheba Medical Center, Ramat Gan, and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel (Y.B., I.G.)
| | - Ilan Goldenberg
- From the Heart Research Follow-up Program, Division of Cardiology, Department of Medicine at the University of Rochester Medical Center, NY (Y.B., V.K., I.C., I.G., H.K., S.M., B.P., A.C.R., M.H.R., A.J.M., W.Z.); Department of Cardiology, Gentofte University Hospital, Copenhagen, Denmark (A.C.R., M.H.R.); and Heart Institute, Sheba Medical Center, Ramat Gan, and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel (Y.B., I.G.)
| | - Helmut Klein
- From the Heart Research Follow-up Program, Division of Cardiology, Department of Medicine at the University of Rochester Medical Center, NY (Y.B., V.K., I.C., I.G., H.K., S.M., B.P., A.C.R., M.H.R., A.J.M., W.Z.); Department of Cardiology, Gentofte University Hospital, Copenhagen, Denmark (A.C.R., M.H.R.); and Heart Institute, Sheba Medical Center, Ramat Gan, and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel (Y.B., I.G.)
| | - Scott McNitt
- From the Heart Research Follow-up Program, Division of Cardiology, Department of Medicine at the University of Rochester Medical Center, NY (Y.B., V.K., I.C., I.G., H.K., S.M., B.P., A.C.R., M.H.R., A.J.M., W.Z.); Department of Cardiology, Gentofte University Hospital, Copenhagen, Denmark (A.C.R., M.H.R.); and Heart Institute, Sheba Medical Center, Ramat Gan, and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel (Y.B., I.G.)
| | - Bronislava Polonsky
- From the Heart Research Follow-up Program, Division of Cardiology, Department of Medicine at the University of Rochester Medical Center, NY (Y.B., V.K., I.C., I.G., H.K., S.M., B.P., A.C.R., M.H.R., A.J.M., W.Z.); Department of Cardiology, Gentofte University Hospital, Copenhagen, Denmark (A.C.R., M.H.R.); and Heart Institute, Sheba Medical Center, Ramat Gan, and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel (Y.B., I.G.)
| | - Anne Christine Ruwald
- From the Heart Research Follow-up Program, Division of Cardiology, Department of Medicine at the University of Rochester Medical Center, NY (Y.B., V.K., I.C., I.G., H.K., S.M., B.P., A.C.R., M.H.R., A.J.M., W.Z.); Department of Cardiology, Gentofte University Hospital, Copenhagen, Denmark (A.C.R., M.H.R.); and Heart Institute, Sheba Medical Center, Ramat Gan, and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel (Y.B., I.G.)
| | - Martin H. Ruwald
- From the Heart Research Follow-up Program, Division of Cardiology, Department of Medicine at the University of Rochester Medical Center, NY (Y.B., V.K., I.C., I.G., H.K., S.M., B.P., A.C.R., M.H.R., A.J.M., W.Z.); Department of Cardiology, Gentofte University Hospital, Copenhagen, Denmark (A.C.R., M.H.R.); and Heart Institute, Sheba Medical Center, Ramat Gan, and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel (Y.B., I.G.)
| | - Arthur J. Moss
- From the Heart Research Follow-up Program, Division of Cardiology, Department of Medicine at the University of Rochester Medical Center, NY (Y.B., V.K., I.C., I.G., H.K., S.M., B.P., A.C.R., M.H.R., A.J.M., W.Z.); Department of Cardiology, Gentofte University Hospital, Copenhagen, Denmark (A.C.R., M.H.R.); and Heart Institute, Sheba Medical Center, Ramat Gan, and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel (Y.B., I.G.)
| | - Wojciech Zareba
- From the Heart Research Follow-up Program, Division of Cardiology, Department of Medicine at the University of Rochester Medical Center, NY (Y.B., V.K., I.C., I.G., H.K., S.M., B.P., A.C.R., M.H.R., A.J.M., W.Z.); Department of Cardiology, Gentofte University Hospital, Copenhagen, Denmark (A.C.R., M.H.R.); and Heart Institute, Sheba Medical Center, Ramat Gan, and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel (Y.B., I.G.)
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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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Stabile G, D’Onofrio A, Pepi P, Simone AD, Santamaria M, Caico SI, Rapacciuolo A, Padeletti L, Pecora D, Giovannini T, Arena G, Spotti A, Iuliano A, Bertaglia E, Malacrida M, Botto GL. Interlead anatomic and electrical distance predict outcome in CRT patients. Heart Rhythm 2015; 12:2221-9. [DOI: 10.1016/j.hrthm.2015.05.020] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2015] [Indexed: 12/15/2022]
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Roubicek T, Wichterle D, Kucera P, Nedbal P, Kupec J, Sedlakova J, Cerny J, Stros J, Kautzner J, Polasek R. Left Ventricular Lead Electrical Delay Is a Predictor of Mortality in Patients With Cardiac Resynchronization Therapy. Circ Arrhythm Electrophysiol 2015; 8:1113-21. [DOI: 10.1161/circep.115.003004] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2015] [Accepted: 08/17/2015] [Indexed: 01/21/2023]
Affiliation(s)
- Tomas Roubicek
- From the Department of Cardiology, Regional Hospital Liberec, Liberec, Czech Republic (T.R., P.K., P.N., J. Kupec, J. Sedlakova, J.C., J. Stros, R.P.); Department of Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic (D.W., J. Kautzner); and Institute of Health Studies, Technical University of Liberec, Liberec, Czech Republic (D.W., J. Kautzner, R.P.)
| | - Dan Wichterle
- From the Department of Cardiology, Regional Hospital Liberec, Liberec, Czech Republic (T.R., P.K., P.N., J. Kupec, J. Sedlakova, J.C., J. Stros, R.P.); Department of Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic (D.W., J. Kautzner); and Institute of Health Studies, Technical University of Liberec, Liberec, Czech Republic (D.W., J. Kautzner, R.P.)
| | - Pavel Kucera
- From the Department of Cardiology, Regional Hospital Liberec, Liberec, Czech Republic (T.R., P.K., P.N., J. Kupec, J. Sedlakova, J.C., J. Stros, R.P.); Department of Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic (D.W., J. Kautzner); and Institute of Health Studies, Technical University of Liberec, Liberec, Czech Republic (D.W., J. Kautzner, R.P.)
| | - Pavel Nedbal
- From the Department of Cardiology, Regional Hospital Liberec, Liberec, Czech Republic (T.R., P.K., P.N., J. Kupec, J. Sedlakova, J.C., J. Stros, R.P.); Department of Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic (D.W., J. Kautzner); and Institute of Health Studies, Technical University of Liberec, Liberec, Czech Republic (D.W., J. Kautzner, R.P.)
| | - Jindrich Kupec
- From the Department of Cardiology, Regional Hospital Liberec, Liberec, Czech Republic (T.R., P.K., P.N., J. Kupec, J. Sedlakova, J.C., J. Stros, R.P.); Department of Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic (D.W., J. Kautzner); and Institute of Health Studies, Technical University of Liberec, Liberec, Czech Republic (D.W., J. Kautzner, R.P.)
| | - Jana Sedlakova
- From the Department of Cardiology, Regional Hospital Liberec, Liberec, Czech Republic (T.R., P.K., P.N., J. Kupec, J. Sedlakova, J.C., J. Stros, R.P.); Department of Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic (D.W., J. Kautzner); and Institute of Health Studies, Technical University of Liberec, Liberec, Czech Republic (D.W., J. Kautzner, R.P.)
| | - Jan Cerny
- From the Department of Cardiology, Regional Hospital Liberec, Liberec, Czech Republic (T.R., P.K., P.N., J. Kupec, J. Sedlakova, J.C., J. Stros, R.P.); Department of Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic (D.W., J. Kautzner); and Institute of Health Studies, Technical University of Liberec, Liberec, Czech Republic (D.W., J. Kautzner, R.P.)
| | - Jan Stros
- From the Department of Cardiology, Regional Hospital Liberec, Liberec, Czech Republic (T.R., P.K., P.N., J. Kupec, J. Sedlakova, J.C., J. Stros, R.P.); Department of Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic (D.W., J. Kautzner); and Institute of Health Studies, Technical University of Liberec, Liberec, Czech Republic (D.W., J. Kautzner, R.P.)
| | - Josef Kautzner
- From the Department of Cardiology, Regional Hospital Liberec, Liberec, Czech Republic (T.R., P.K., P.N., J. Kupec, J. Sedlakova, J.C., J. Stros, R.P.); Department of Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic (D.W., J. Kautzner); and Institute of Health Studies, Technical University of Liberec, Liberec, Czech Republic (D.W., J. Kautzner, R.P.)
| | - Rostislav Polasek
- From the Department of Cardiology, Regional Hospital Liberec, Liberec, Czech Republic (T.R., P.K., P.N., J. Kupec, J. Sedlakova, J.C., J. Stros, R.P.); Department of Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic (D.W., J. Kautzner); and Institute of Health Studies, Technical University of Liberec, Liberec, Czech Republic (D.W., J. Kautzner, R.P.)
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Mafi Rad M, Wijntjens GWM, Engels EB, Blaauw Y, Luermans JGLM, Pison L, Crijns HJ, Prinzen FW, Vernooy K. Vectorcardiographic QRS area identifies delayed left ventricular lateral wall activation determined by electroanatomic mapping in candidates for cardiac resynchronization therapy. Heart Rhythm 2015; 13:217-25. [PMID: 26232766 DOI: 10.1016/j.hrthm.2015.07.033] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2015] [Indexed: 11/26/2022]
Abstract
BACKGROUND Delayed left ventricular (LV) lateral wall (LVLW) activation is considered the electrical substrate underlying LV dysfunction amenable to cardiac resynchronization therapy (CRT). OBJECTIVE The purpose of this study was to assess LVLW activation in CRT candidates using coronary venous electroanatomic mapping (EAM) and to investigate whether the QRS area (QRSAREA) on the vectorcardiogram (VCG) can identify delayed LVLW activation. METHODS Fifty-one consecutive CRT candidates (29 left bundle branch block [LBBB], 15 intraventricular conduction delay [IVCD], 7 right bundle branch block [RBBB]) underwent intraprocedural coronary venous EAM using EnSite NavX. VCGs were constructed from preprocedural digital 12-lead ECGs using the Kors method. QRSAREA was assessed and compared to QRS duration and 5 different LBBB definitions. RESULTS Delayed LVLW activation (activation time >75% of QRS duration) occurred in 38 of 51 patients (29/29 LBBB, 8/15 IVCD, 1/7 RBBB). QRSAREA was larger in patients with than in patients without delayed LVLW activation (108 ± 42 µVs vs 51 ± 27 µVs, P < .001), and identified delayed LVLW activation better than QRS duration (area under the curve 0.89 [95% confidence interval 0.79-0.99] vs 0.49 [95% confidence interval 0.33-0.65]). QRSAREA >69 µVs diagnosed delayed LVLW activation with a higher sum of sensitivity (87%) and specificity (92%) than any of the LBBB definitions. Of the different LBBB definitions, the European Society of Cardiology textbook definition performed best with sensitivity of 76% and specificity of 100%. CONCLUSION Coronary venous EAM can be used during CRT implantation to determine the presence of delayed LVLW activation. QRSAREA is a noninvasive alternative for intracardiac measurements of electrical activation, which identifies delayed LVLW activation better than QRS duration and LBBB morphology.
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Affiliation(s)
- Masih Mafi Rad
- Department of Cardiology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Gilbert W M Wijntjens
- Department of Physiology, Maastricht University, Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
| | - Elien B Engels
- Department of Physiology, Maastricht University, Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
| | - Yuri Blaauw
- Department of Cardiology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Justin G L M Luermans
- Department of Cardiology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Laurent Pison
- Department of Cardiology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Harry J Crijns
- Department of Cardiology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Frits W Prinzen
- Department of Physiology, Maastricht University, Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
| | - Kevin Vernooy
- Department of Cardiology, Maastricht University Medical Center, Maastricht, The Netherlands,.
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Kroon W, Lumens J, Potse M, Suerder D, Klersy C, Regoli F, Murzilli R, Moccetti T, Delhaas T, Krause R, Prinzen FW, Auricchio A. In vivo electromechanical assessment of heart failure patients with prolonged QRS duration. Heart Rhythm 2015; 12:1259-67. [DOI: 10.1016/j.hrthm.2015.03.006] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2014] [Indexed: 11/15/2022]
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Fontaine JM, Gupta A, Franklin SM, Kang CU, Whigham LA. Biventricular paced QRS predictors of left ventricular lead locations in relation to mortality in cardiac resynchronization therapy. J Electrocardiol 2015; 48:226-35. [PMID: 25552478 DOI: 10.1016/j.jelectrocard.2014.12.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2014] [Indexed: 11/15/2022]
Abstract
BACKGROUND Left ventricular (LV) lead location during cardiac resynchronization therapy (CRT) has influenced mortality and heart failure events; however the biventricular paced QRS morphology has not been established as a predictor of LV lead location or mortality. METHODS We evaluated the biventricular paced QRS morphology in 306 patients undergoing CRT in relation to specific anatomic locations. A logistic regression model and Kaplan-Meier survival estimates were used to determine predictors of LV lead location and survival. RESULTS The mean age was 68±13years. Predictors of LV lead location from anterior, lateral, and posterior segments were: absence of R in V1, QS in aVL; and R in aVL, respectively. Absence of an R in II, III, or aVF predicted an inferior site. A QS in V4-V6 differentiated apical from basal sites (p=0.01). LV pacing from sites along the middle cardiac vein revealed a higher mortality (34%), than lateral sites (20%, p=0.02). CONCLUSIONS Biventricular paced QRS criteria were predictive of LV lead locations. The proposed algorithm enhanced the predictive accuracy of these criteria. LV pacing sites along the middle cardiac vein were associated with increased mortality.
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Affiliation(s)
- John M Fontaine
- Division of Cardiology, Electrophysiology Section, Drexel University College of Medicine, Philadelphia, PA, USA.
| | - Ashwani Gupta
- Division of Cardiology, Electrophysiology Section, Drexel University College of Medicine, Philadelphia, PA, USA
| | - Sona M Franklin
- Division of Cardiology, Electrophysiology Section, Drexel University College of Medicine, Philadelphia, PA, USA
| | - Christina U Kang
- Division of Cardiology, Electrophysiology Section, Drexel University College of Medicine, Philadelphia, PA, USA
| | - Latrisha A Whigham
- Division of Cardiology, Electrophysiology Section, Drexel University College of Medicine, Philadelphia, PA, USA
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Upadhyay GA, Chatterjee NA, Kandala J, Friedman DJ, Park MY, Tabtabai SR, Hung J, Singh JP. Assessing mitral regurgitation in the prediction of clinical outcome after cardiac resynchronization therapy. Heart Rhythm 2015; 12:1201-8. [PMID: 25708879 DOI: 10.1016/j.hrthm.2015.02.022] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2014] [Indexed: 12/12/2022]
Abstract
BACKGROUND Cardiac resynchronization therapy (CRT) has been shown to reduce mitral regurgitation (MR), although the clinical impact of this improvement remains uncertain. OBJECTIVES We sought to evaluate the impact of MR improvement on clinical outcome after CRT and to assess predictors and mechanism for change in MR. METHODS This was a cohort study of patients undergoing CRT for conventional indications with baseline and follow-up echocardiography (at 6 months). MR severity was classified into 4 grades. The primary end point was time to all-cause death or time to first heart failure (HF) hospitalization assessed at 3 years. RESULTS A total of 439 patients were included: median age was 70.2 years, 90 (20.5%) were women, 255 (58.1%) with ischemic cardiomyopathy, and mean QRS width was 162 ms. Worsening severity of baseline MR was independently predictive of HF or all-cause mortality (hazard ratio 1.33; 95% confidence interval 1.01-1.75; P = .042). Reduction in MR after CRT was significantly associated with lower HF hospitalization and improved survival (hazard ratio 0.65; 95% confidence interval 0.49-0.85; P = .002). Degree of baseline MR and longer surface QRS to left ventricular lead time were significant predictors of MR change. Patients with MR reduction exhibited lower mitral valve tenting area (P < .001) and coaptation height (P < .001) than those with stable or worsening MR, suggestive of improved ventricular geometry as a mechanism for change in MR. CONCLUSION Degree of baseline MR and change in MR after CRT predicted all-cause mortality and HF hospitalization at 3 years. Longer surface QRS to left ventricular lead time at implant may be a means to target MR improvement.
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Affiliation(s)
- Gaurav A Upadhyay
- Cardiac Arrhythmia Service, Massachusetts General Hospital, Boston, Massachusetts; Heart Rhythm Center, Section of Cardiology, University of Chicago, Chicago, Illinois
| | | | - Jagdesh Kandala
- Cardiac Arrhythmia Service, Massachusetts General Hospital, Boston, Massachusetts
| | - Daniel J Friedman
- Cardiac Arrhythmia Service, Massachusetts General Hospital, Boston, Massachusetts
| | - Mi-Young Park
- Echocardiography Laboratory of the Massachusetts General Hospital, Boston, Massachusetts
| | | | - Judy Hung
- Echocardiography Laboratory of the Massachusetts General Hospital, Boston, Massachusetts
| | - Jagmeet P Singh
- Cardiac Arrhythmia Service, Massachusetts General Hospital, Boston, Massachusetts.
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Zhang H, Dai Z, Xiao P, Pan C, Zhang J, Hu Z, Chen S. The Left Ventricular Lead Electrical Delay Predicts Response to Cardiac Resynchronisation Therapy. Heart Lung Circ 2014; 23:936-42. [DOI: 10.1016/j.hlc.2014.04.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2013] [Revised: 02/15/2014] [Accepted: 04/03/2014] [Indexed: 10/25/2022]
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Mafi Rad M, Blaauw Y, Dinh T, Pison L, Crijns HJ, Prinzen FW, Vernooy K. Left ventricular lead placement in the latest activated region guided by coronary venous electroanatomic mapping. Europace 2014; 17:84-93. [DOI: 10.1093/europace/euu221] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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