Cardiac resynchronization therapy in the real world: need to focus on implant rates, patient selection, co-morbidities, type of devices, and complications

What determines who gets cardiac resynchronization therapy in Europe? A comparison between ESC-HF-LT registry, SwedeHF registry, and ESC-CRT Survey II

AIMS

Cardiac resynchronization therapy (CRT) is effective in heart failure with reduced ejection fraction (HFrEF) and dyssynchrony but is underutilized. In a cohort study, we identified clinical, organizational, and level of care factors linked to CRT implantation.

METHODS AND RESULTS

We included HFrEF patients fulfilling study criteria in the ESC-HF-Long Term Registry (ESC-HF-LT, n = 1031), the Swedish Heart Failure Registry (SwedeHF) (n = 5008), and the ESC-CRT Survey II (n = 11 088). In ESC-HF-LT, 36% had a CRT indication of which 47% had CRT, 53% had indication but no CRT, and the remaining 54% had no indication and no CRT. In SwedeHF, these percentages were 30, 25, 75, and 70%. Median age of patients with CRT indication and CRT present vs. absent was 68 vs. 65 years with 24% vs. 22% women in ESC-HF-LT, 76 vs. 74 years with 26% vs. 26% women in SwedeHF, and 70 years with 24% women in CRT Survey II (all had CRT). For ESC-HF-LT, independent predictors of having CRT were guideline-directed medical therapy (GDMT), atrial fibrillation (AF), prior HF hospitalization, and NYHA class. For SwedeHF, they were GDMT, age, AF, previous myocardial infarction, lower NYHA class, enrolment at university hospital, and follow-up at HF centre/Hospital. In SwedeHF, above median income and higher education level were also independently associated with having CRT. In the ESC-CRT Survey II (n = 11 088), all patients received CRT but with differences in the clinical characteristics between countries.

CONCLUSION

CRT was used in a minority of eligible patients and more used in ESC-HF-LT than in SwedeHF.

ObsErvatioNal prospective multicenter stuDy tO characterize the cLinical ANd DiagnoStiC feAtures of endocarditis in the contemPorary Era (ENDO-LANDSCAPE study): rationale and design

BACKGROUND

Recent developments in the management of valvular heart disease and heart failure have resulted in a dramatic increase in percutaneous valve procedures and implanted devices. We hypothesize that this has impacted the epidemiology, diagnosis, and management of endocarditis.

METHODS

The obsErvatioNal prospective multicenter stuDy tO characterize the cLinical ANd DiagnoStiC feAtures of endocarditis in the contemPorary Era (ENDO-LANDSCAPE study) is an observational, multicenter, and international study aimed to examine the epidemiology of endocarditis in the contemporary era. The study will constitute of a retrospective arm for the determination of the sample size of the prospective arm, where cases of endocarditis between 2016 to 2022 at three tertiary referral institutions will be analyzed. The prospective arm will examine all consecutive patients referred for an echocardiography with a suspected or confirmed diagnosis of endocarditis, and their clinical course followed up over 12 months for adverse outcomes. The primary aim of the study will be to characterize the epidemiology of endocarditis, focusing on patients with prosthetic or implanted devices. The secondary aims would be: the appropriateness of the requests for first-line echocardiographic imaging in exclusion of endocarditis; the role of other imaging modalities in the diagnosis of endocarditis; and the impact of a specialized endocarditis team on outcomes.

IMPLICATIONS

The results of the ENDO-LANDSCAPE study will provide a contemporary update of the epidemiological trends in endocarditis. The data generated from this study would be useful in informing future clinical practice, potentially guiding future diagnostic and treatment algorithms in patients with endocarditis.

CLINICALTRIALORG ID

NCT05547607.

A Novel Approach for Repetitive Dislocation of Transvenous Left Ventricular Leads During Cardiac Resynchronization Therapy Implantation by the Loop Technique

Cardiac resynchronization therapy (CRT) for heart failure requires transvenous insertion of a left ventricular pacing lead through the coronary sinus. However, repeated intraoperative dislocations often occur. Therefore, we describe a novel technique that uses the loop technique to treat patients with repeated intraoperative dislocations during transvenous left ventricular lead implantation to stabilize the lead in its final position. In five patients with repeated intraoperative dislocation during transvenous left ventricular lead implantation, the loop technique was successfully used to stabilize the lead in its final position. The pacing and sensing parameters were satisfactory in all patients at implantation and 12 months post-operatively. Compared with the pre-operative values, the 12-month post-operative values for the left ventricular ejection fraction were significantly increased and the left ventricular end systolic dimension and left ventricular end diastolic dimension were significantly decreased (P < 0.05). The left ventricular ejection fraction of these 5 patients increased by more than 15%. CRT significantly improved the left ventricular structure and function of these 5 patients. During the 1-, 3-, 6-, and 12-month follow-ups, no left ventricular lead dislocations were observed. This loop technique is safe and effective and can be considered for repeated intraoperative dislocation during transvenous left ventricular lead implantation through the coronary sinus of a CRT device.

Heart failure in the last year: progress and perspective

Research about heart failure (HF) has made major progress in the last years. We give here an update on the most recent findings. Landmark trials have established new treatments for HF with reduced ejection fraction. Sacubitril/valsartan was superior to enalapril in PARADIGM-HF trial, and its initiation during hospitalization for acute HF or early after discharge can now be considered. More recently, new therapeutic pathways have been developed. In the DAPA-HF and EMPEROR-Reduced trials, dapagliflozin and empagliflozin reduced the risk of the primary composite endpoint, compared with placebo [hazard ratio (HR) 0.74; 95% confidence interval (CI) 0.65-0.85; P < 0.001 and HR 0.75; 95% CI 0.65-0.86; P < 0.001, respectively]. Second, vericiguat, an oral soluble guanylate cyclase stimulator, reduced the composite endpoint of cardiovascular death or HF hospitalization vs. placebo (HR 0.90; 95% CI 0.82-0.98; P = 0.02). On the other hand, both the diagnosis and treatment of HF with preserved ejection fraction, as well as management of advanced HF and acute HF, remain challenging. A better phenotyping of patients with HF would be helpful for prognostic stratification and treatment selection. Further aspects, such as the use of devices, treatment of arrhythmias, and percutaneous treatment of valvular heart disease in patients with HF, are also discussed and reviewed in this article.