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Meyer M, Infeld M, Habel N, Lustgarten D. Personalized accelerated physiologic pacing. Eur Heart J Suppl 2023; 25:G33-G43. [PMID: 37970518 PMCID: PMC10637836 DOI: 10.1093/eurheartjsupp/suad117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2023]
Abstract
Heart failure with preserved ejection fraction (HFpEF) is increasingly prevalent with a high socioeconomic burden. Pharmacological heart rate lowering was recommended to improve ventricular filling in HFpEF. This article discusses the misperceptions that have resulted in an overprescription of beta-blockers, which in all likelihood have untoward effects on patients with HFpEF, even if they have atrial fibrillation or coronary artery disease as a comorbidity. Directly contradicting the lower heart rate paradigm, faster heart rates provide haemodynamic and structural benefits, amongst which lower cardiac filling pressures and improved ventricular capacitance may be most important. Safe delivery of this therapeutic approach is feasible with atrial and ventricular conduction system pacing that aims to emulate or enhance cardiac excitation to maximize the haemodynamic benefits of accelerated pacing. This conceptual framework was first tested in the myPACE randomized controlled trial of patients with pre-existing pacemakers and preclinical or overt HFpEF. This article provides the background and path towards this treatment approach.
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Affiliation(s)
- Markus Meyer
- Department of Medicine, Larner College of Medicine, University of Vermont, Burlington, 111 Colchester Avenue, McClure Level 1, Burlington, VT 05401, USA
- Department of Medicine, Lillehei Heart Institute, University of Minnesota College of Medicine, 2231 6th St. SE, 4-165 CCRB, Minneapolis, MN 55455, USA
| | - Margaret Infeld
- Department of Medicine, Larner College of Medicine, University of Vermont, Burlington, 111 Colchester Avenue, McClure Level 1, Burlington, VT 05401, USA
- Cardiovascular Center, Tufts Medical Center and Tufts University School of Medicine, 800 Washington Street, Boston, MA 02111, USA
| | - Nicole Habel
- Department of Medicine, Larner College of Medicine, University of Vermont, Burlington, 111 Colchester Avenue, McClure Level 1, Burlington, VT 05401, USA
| | - Daniel Lustgarten
- Department of Medicine, Larner College of Medicine, University of Vermont, Burlington, 111 Colchester Avenue, McClure Level 1, Burlington, VT 05401, USA
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Tsigkriki L, Kleitsioti P, Dimitriadis F, Sidiropoulos G, Alkagiet S, Efstratiou D, Kalaitzoglou M, Charisopoulou D, Siarkos M, Mavrogianni AD, Giannakopoulou P, Zarifis J, Koulaouzidis G. The Utility of Low-Dose-Dobutamine Stress Echocardiography in Patients with Heart Failure with Reduced Ejection Fraction: An Update. Diagnostics (Basel) 2023; 13:2920. [PMID: 37761286 PMCID: PMC10527914 DOI: 10.3390/diagnostics13182920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 09/08/2023] [Accepted: 09/09/2023] [Indexed: 09/29/2023] Open
Abstract
Despite significant advancements in medical therapy, heart failure with reduced ejection fraction (HFrEF) continues to be a significant cause of death and disability. Reversible ischaemic left ventricular dysfunction due to viable myocardium is one such contributing factor. In these cases, coronary revascularization has shown promise in improving left ventricular function and prognosis. For patients with HFrEF and wide QRS, cardiac resynchronization therapy (CRT) is an effective option to address electromechanical dyssynchrony. However, approximately 30% of patients do not respond positively to CRT, highlighting the need to refine candidate selection for this treatment. In some patients with reduced HFrEF, there is a condition known as classical low-flow, low-gradient aortic stenosis (AS) that may be observed. This condition is characterized by a low transaortic flow, which leads to reductions in both the transaortic mean gradient and aortic valve area. Decision-making regarding revascularization, CRT, and pharmacological treatment play a crucial role in managing HFrEF. Cardiac imaging can be valuable in guiding decision-making processes and assessing the prognosis of patients with HFrEF. Among the imaging modalities, dobutamine stress echocardiography has come a long way in establishing itself as a feasible, safe, effective, relatively cheap non-invasive technique. The aim of this review is to explore the current literature on the utility of low-dose stress echocardiography in diagnosing and prognosticating patients with HFrEF.
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Affiliation(s)
- Lamprini Tsigkriki
- Cardiology Department, General Hospital G. Papanikolaou, 57010 Thessaloniki, Greece; (L.T.); (P.K.); (F.D.); (G.S.); (S.A.); (D.E.); (M.K.); (M.S.); (A.-D.M.); (P.G.); (J.Z.)
| | - Panagiota Kleitsioti
- Cardiology Department, General Hospital G. Papanikolaou, 57010 Thessaloniki, Greece; (L.T.); (P.K.); (F.D.); (G.S.); (S.A.); (D.E.); (M.K.); (M.S.); (A.-D.M.); (P.G.); (J.Z.)
| | - Fotis Dimitriadis
- Cardiology Department, General Hospital G. Papanikolaou, 57010 Thessaloniki, Greece; (L.T.); (P.K.); (F.D.); (G.S.); (S.A.); (D.E.); (M.K.); (M.S.); (A.-D.M.); (P.G.); (J.Z.)
| | - George Sidiropoulos
- Cardiology Department, General Hospital G. Papanikolaou, 57010 Thessaloniki, Greece; (L.T.); (P.K.); (F.D.); (G.S.); (S.A.); (D.E.); (M.K.); (M.S.); (A.-D.M.); (P.G.); (J.Z.)
| | - Stelina Alkagiet
- Cardiology Department, General Hospital G. Papanikolaou, 57010 Thessaloniki, Greece; (L.T.); (P.K.); (F.D.); (G.S.); (S.A.); (D.E.); (M.K.); (M.S.); (A.-D.M.); (P.G.); (J.Z.)
| | - Dimitris Efstratiou
- Cardiology Department, General Hospital G. Papanikolaou, 57010 Thessaloniki, Greece; (L.T.); (P.K.); (F.D.); (G.S.); (S.A.); (D.E.); (M.K.); (M.S.); (A.-D.M.); (P.G.); (J.Z.)
| | - Maria Kalaitzoglou
- Cardiology Department, General Hospital G. Papanikolaou, 57010 Thessaloniki, Greece; (L.T.); (P.K.); (F.D.); (G.S.); (S.A.); (D.E.); (M.K.); (M.S.); (A.-D.M.); (P.G.); (J.Z.)
| | | | - Michail Siarkos
- Cardiology Department, General Hospital G. Papanikolaou, 57010 Thessaloniki, Greece; (L.T.); (P.K.); (F.D.); (G.S.); (S.A.); (D.E.); (M.K.); (M.S.); (A.-D.M.); (P.G.); (J.Z.)
| | - Angeliki-Despoina Mavrogianni
- Cardiology Department, General Hospital G. Papanikolaou, 57010 Thessaloniki, Greece; (L.T.); (P.K.); (F.D.); (G.S.); (S.A.); (D.E.); (M.K.); (M.S.); (A.-D.M.); (P.G.); (J.Z.)
| | - Pinelopi Giannakopoulou
- Cardiology Department, General Hospital G. Papanikolaou, 57010 Thessaloniki, Greece; (L.T.); (P.K.); (F.D.); (G.S.); (S.A.); (D.E.); (M.K.); (M.S.); (A.-D.M.); (P.G.); (J.Z.)
| | - John Zarifis
- Cardiology Department, General Hospital G. Papanikolaou, 57010 Thessaloniki, Greece; (L.T.); (P.K.); (F.D.); (G.S.); (S.A.); (D.E.); (M.K.); (M.S.); (A.-D.M.); (P.G.); (J.Z.)
| | - George Koulaouzidis
- Department of Biochemical Sciences, Pomeranian Medical University, 70-204 Szczecin, Poland
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Gold MR, Rickard J, Daubert JC, Cerkvenik J, Linde C. Association of left ventricular remodeling with cardiac resynchronization therapy outcomes. Heart Rhythm 2023; 20:173-180. [PMID: 36442825 DOI: 10.1016/j.hrthm.2022.11.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Revised: 11/17/2022] [Accepted: 11/21/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Cardiac resynchronization therapy (CRT) response stratified by left ventricular (LV) remodeling revealed differing mortality profiles for distinct patient cohorts. Measuring functional end points, as well as mortality, may better assess CRT efficacy and inform patient management. However, the association between LV remodeling and functional outcomes after CRT is not well understood. OBJECTIVE The purpose of this study was to evaluate long-term CRT outcomes by extent of LV remodeling. METHODS REsynchronization reVErses Remodeling in Systolic Left vEntricular dysfunction (ClinicalTrials.gov identifier NCT00271154) was a prospective, double-blind, randomized trial of CRT. Subjects were classified on the basis of LV end-systolic volume (LVESV) change from baseline to 6 months post-CRT: worsened (increase), stabilized (0%-≤15% reduction), responder (>15%-<30% reduction), and super-responder (≥30% reduction). Subjects were evaluated annually for 5 years. RESULTS The analyses included 353 subjects randomized to CRT-ON arm. All-cause mortality was higher in the worsened group than in the other 3 response groups (29.8% vs 8.0%; P < .0001), with no difference in survival among those groups (P = .87). A significant interaction between the LVESV group and time was observed for health status and quality of life (P = .02 for both). The interaction was not significant for 6-minute hall walk (P = .79); however, super-responders had increased walk distance compared with the other 3 response groups (P = .03). CONCLUSION Preventing further increase in LVESV with CRT was associated with reduced mortality, whereas functional measure improvement was associated with LV remodeling magnitude. These results support the consideration of functional and mortality end points to assess CRT efficacy and provide further evidence that the dichotomous "responder and nonresponder" classification should be modified.
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Affiliation(s)
- Michael R Gold
- Department of Medicine, Medical University of South Carolina, Charleston, South Carolina.
| | - John Rickard
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - J Claude Daubert
- Faculty of Medicine, University of Rennes 1, CIC IT, INSERM 642, Rennes, France
| | | | - Cecilia Linde
- Department of Medicine, Cardiology Unit, Karolinska Institute and Karolinska University Hospital, Stockholm, Sweden
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Orlov MV. Redefining the response to CRT: Mission possible? Heart Rhythm 2023; 20:171-172. [PMID: 36435349 DOI: 10.1016/j.hrthm.2022.11.011] [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: 11/21/2022] [Accepted: 11/22/2022] [Indexed: 11/24/2022]
Affiliation(s)
- Michael V Orlov
- Division of Cardiology, Steward St. Elizabeth's Medical Center, Tufts University School of Medicine, Boston, Massachusetts; Boston University School of Medicine, Boston, Massachusetts.
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Pardo-Cabello AJ, Manzano-Gamero V, Puche-Cañas E. Placebo: a brief updated review. Naunyn Schmiedebergs Arch Pharmacol 2022; 395:1343-1356. [PMID: 35943515 PMCID: PMC9361274 DOI: 10.1007/s00210-022-02280-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Accepted: 08/03/2022] [Indexed: 11/04/2022]
Abstract
Our aims were to provide updated information on placebo/nocebo effect and the potential use of placebo in clinical practice. This article can only provide a rough overview on the placebo and nocebo effect and is intended to serve as a starting point for the reader to go deeper into the corresponding literature. The placebo effect has been observed in multiple medical conditions, after oral administration, with manual therapies as well as with surgery and invasive procedures. The use of placebo in clinical trials is fundamental, although the ethics of its use is under discussion. The placebo may behave like a drug from the pharmacokinetic and pharmacodynamic point of view and can also be associated with adverse events (nocebo effect). Placebo can modify treatment by increasing or decreasing the effects of drugs. The factors associated with the occurrence of placebo effect are multiple, but in addition to those that depend on the placebo itself, the doctor-patient relationship would be the most important. As a result of findings that were published in the last two decades, the psycho-neurobiological basis of placebo is becoming better understood, although further studies are needed. In conclusion, the placebo effect in the clinic exhibits weak to moderate intensity. Placebo, in addition to its use in the clinical trial, should be considered another therapeutic remedy either as stand alone or in association with treatment, and could be useful in certain circumstances. The use of placebo should be regulated by the European health authorities through a guide in clinical practice that will improve patient care.
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Affiliation(s)
- Alfredo Jose Pardo-Cabello
- Department of Internal Medicine, Hospital Universitario San Cecilio, Avda. de La Innovación, s/n, 18016, Granada, Spain.
| | - Victoria Manzano-Gamero
- Department of Internal Medicine, Hospital Universitario Virgen de Las Nieves, Granada, Spain
| | - Emilio Puche-Cañas
- Department of Pharmacology, School of Medicine, University of Granada, Granada, Spain
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Green PG, Herring N, Betts TR. What Have We Learned in the Last 20 Years About CRT Non-Responders? Card Electrophysiol Clin 2022; 14:283-296. [PMID: 35715086 DOI: 10.1016/j.ccep.2021.12.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Although cardiac resynchronization therapy (CRT) has become well established in the treatment of heart failure, the management of patients who do not respond after CRT remains a key challenge. This review will summarize what we have learned about non-responders over the last 20 years and discuss methods for optimizing response, including the introduction of novel therapies.
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Affiliation(s)
- Peregrine G Green
- Department of Physiology, Anatomy and Genetics, University of Oxford, Sherrington Building, Parks Road, Oxford, OX1 3PT, UK; Oxford Centre for Clinical Magnetic Resonance Research (OCMR), University of Oxford, Level 0 John Radcliffe Hospital, Oxford, OX3 9DU, UK; Oxford Heart Centre, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, OX3 9DU, UK
| | - Neil Herring
- Department of Physiology, Anatomy and Genetics, University of Oxford, Sherrington Building, Parks Road, Oxford, OX1 3PT, UK; Oxford Heart Centre, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, OX3 9DU, UK
| | - Timothy R Betts
- Oxford Heart Centre, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, OX3 9DU, UK; Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.
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Kaza N, Keene D, Whinnett ZI. Generating Evidence to Support the Physiologic Promise of Conduction System Pacing: Status and Update on Conduction System Pacing Trials. Card Electrophysiol Clin 2022; 14:345-355. [PMID: 35715090 DOI: 10.1016/j.ccep.2022.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Conduction system pacing avoids the potential deleterious effects of right ventricular pacing in patients with bradycardia and provides an alternative approach to cardiac resynchronization therapy. We focus on the available observational and randomized evidence and review studies supporting the safety, feasibility, and physiologic promise of conduction system approaches. We evaluate the randomized data generated from the available clinical trials of conduction system pacing, which have led to the recent inclusion of CSP in international guidelines. The scope for future randomized trials will building on the physiologic promise of conduction system approaches and offering information on clinical end points is explored.
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Affiliation(s)
- Nandita Kaza
- National Heart and Lung Institute, Imperial College London, Hammersmith Hospital, London W12 0HS, UK
| | - Daniel Keene
- National Heart and Lung Institute, Imperial College London, Hammersmith Hospital, London W12 0HS, UK.
| | - Zachary I Whinnett
- National Heart and Lung Institute, Imperial College London, Hammersmith Hospital, London W12 0HS, UK
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Cang J, Liu Y, Zhu D, Liu S, Shen J, Miao H, Zhou Q, Chen L. WiSE CRT Is Beneficial for Heart Failure Patients as a Rescue Therapy: Evidence From a Meta-Analysis. Front Cardiovasc Med 2022; 9:823797. [PMID: 35369306 PMCID: PMC8964787 DOI: 10.3389/fcvm.2022.823797] [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: 11/28/2021] [Accepted: 02/08/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundLeadless endocardial left ventricular (LV) pacing resynchronization therapy is a novel solution for patients with heart failure (HF) in whom conventional cardiac resynchronization therapy (CRT) failed.MethodsPubMed and the Cochrane Library were searched for relevant cohort studies. Clinical outcomes of interest such as ejection fraction (EF), QRS duration (QRSd), and left ventricular end-systolic volume (LVESV) were extracted and analyzed.ResultsFive studies involving 175 HF patients for WiSE CRT were included, and patients were followed-up for 6 months. The implanted success rate ranged from 76.5 to 100%. WiSE CRT resulted in significantly narrower QRSd [mean difference (MD): −38.21 ms, 95% confidence interval (CI): −44.36 to −32.07, p < 0.001], improved left ventricular ejection fraction (MD: 6.07%, 95% CI: 4.43 to 7.71, I2 = 0%, p < 0.001), reduced left ventricular end-systolic volume (MD: −23.47 ml, 95% CI: −37.18 to −9.13, p < 0.001), and reduced left ventricular end-diastolic volume (MD: −24.02 ml, 95% CI: −37.01 to −11.03, p = 0.02).ConclusionEvidence from current studies suggests that leadless endocardial LV pacing resynchronization is effective for HF patients who failed conventional CRT or needed a device upgrade, and it may be an interesting rescue therapy.
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Okabe T, Hummel JD, Bank AJ, Niazi IK, McGrew FA, Kindsvater S, Oza SR, Scherschel JA, Walsh MN, Singh JP. Leadless left ventricular stimulation with WiSE-CRT System - Initial experience and results from phase I of SOLVE-CRT Study (nonrandomized, roll-in phase). Heart Rhythm 2021; 19:22-29. [PMID: 34332966 DOI: 10.1016/j.hrthm.2021.06.1195] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 06/18/2021] [Accepted: 06/23/2021] [Indexed: 11/04/2022]
Abstract
BACKGROUND Left ventricular (LV) endocardial pacing is a promising method to deliver cardiac resynchronization therapy (CRT). WiSE-CRT is a wireless LV endocardial pacing system, and delivers ultrasonic energy to an LV electrode. OBJECTIVE The purpose of this study was to present short-term outcomes with the WiSE-CRT system in centers with no prior implanting experience. METHODS Data were prospectively collected from 19 centers where WiSE-CRT systems were implanted during the roll-in phase of the SOLVE-CRT trial. Patients were followed at 1, 3, and 6 months, including transthoracic echo (TTE) at 6 months. RESULTS The WiSE-CRT was successfully implanted in all 31 attempted cases, and 30 patients completed the 6-month follow-up. One patient underwent heart transplantation 1 month after implantation, and was excluded. Fourteen (46.7%) patients demonstrated ≥1 NYHA class improvement. TTE data were available in 29 patients. LV ejection fraction, LV end-systolic volume, and LV end-diastolic volume improved from 28.3% ± 6.7% to 33.5% ± 6.9% (P < .001), 134.9 ± 51.3 mL to 111.1 ± 40.3 mL (P = .0004), and 185.4 ± 58.8 mL to 164.9 ± 50.6 mL (P = .0017), respectively. There were 3 (9.7%) device-related type 1 complications: 1 insufficient LV pacing, 1 embolization of an unanchored LV electrode, and 1 skin infection. CONCLUSIONS We demonstrated a high success rate of LV endocardial electrode placement in centers with no prior implanting experience. Favorable clinical responses in heart failure symptoms and significant LV reverse remodeling were noted.
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Affiliation(s)
- Toshimasa Okabe
- The Ohio State University Wexner Medical Center, Columbus, Ohio.
| | - John D Hummel
- The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Alan J Bank
- Minneapolis Heart Institute, Allina Health, St. Paul, Minnesota
| | | | | | | | - Saumil R Oza
- Ascension St. Vincent's Hospital, Jacksonville, Florida
| | | | | | - Jagmeet P Singh
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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Yufu K, Abe I, Kondo H, Saito S, Fukui A, Okada N, Akioka H, Shinohara T, Teshima Y, Nakagawa M, Takahashi N. Distinctively different predictors for long-term outcomes between responders and nonresponders who underwent cardiac resynchronization therapy. J Arrhythm 2021; 37:173-181. [PMID: 33664900 PMCID: PMC7896449 DOI: 10.1002/joa3.12447] [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: 06/27/2020] [Revised: 09/11/2020] [Accepted: 10/08/2020] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND It is common to develop heart failure (HF) events even in respondents to cardiac resynchronization therapy (CRT) during a long-term observation period. We investigated the predictors for long-term outcome in responders in comparison with nonresponders in patients diagnosed with HF along with implanted CRT. METHODS We enrolled 133 consecutive patients (mean age, 70 ± 10 years; 72 males) implanted with CRT from April 2010 to July 2019. Accurate follow-up information (mean follow-up period, 983 ± 801 days) was obtained from 66 responders and 53 nonresponders. RESULTS Kaplan-Meier event-free curves showed that major adverse cerebral and cardiovascular event (MACCE)-free ratio was significantly lower as the stage of renal function progresses (log rank, 19.5; P < .0001). The baseline estimated glomerular filtration rate (e-GFR) before CRT was not significantly different between nonresponders and responders. The e-GFR after judgment of CRT response was lower in patients with MACCEs than those without. Cox proportional hazards regression analysis revealed that low baseline e-GFR before CRT and after judgment of CRT response was closely related with MACCEs in responders, but not in nonresponders. The survival rate in responders without MACCEs assessed using Kaplan-Meier analysis was significantly larger in the preserved e-GFR (baseline value before CRT, >44 mL/min/1.73 m2) group than in the depressed group (log rank, 20.29; P < .0001). CONCLUSION We demonstrate that the factors for MACCEs during long follow-up periods were distinctively different between responders and nonresponders. Patients with depressed e-GFRs are suggested to have poor prognosis even if they are responders to CRT.
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Affiliation(s)
- Kunio Yufu
- Department of Cardiology and Clinical ExaminationFaculty of MedicineOita UniversityOitaJapan
| | - Ichitaro Abe
- Department of Cardiology and Clinical ExaminationFaculty of MedicineOita UniversityOitaJapan
| | - Hidekazu Kondo
- Department of Cardiology and Clinical ExaminationFaculty of MedicineOita UniversityOitaJapan
| | - Shotaro Saito
- Department of Cardiology and Clinical ExaminationFaculty of MedicineOita UniversityOitaJapan
| | - Akira Fukui
- Department of Cardiology and Clinical ExaminationFaculty of MedicineOita UniversityOitaJapan
| | - Norihiro Okada
- Department of Cardiology and Clinical ExaminationFaculty of MedicineOita UniversityOitaJapan
| | - Hidefumi Akioka
- Department of Cardiology and Clinical ExaminationFaculty of MedicineOita UniversityOitaJapan
| | - Tetsuji Shinohara
- Department of Cardiology and Clinical ExaminationFaculty of MedicineOita UniversityOitaJapan
| | - Yasushi Teshima
- Department of Cardiology and Clinical ExaminationFaculty of MedicineOita UniversityOitaJapan
| | - Mikiko Nakagawa
- Department of Cardiology and Clinical ExaminationFaculty of MedicineOita UniversityOitaJapan
| | - Naohiko Takahashi
- Department of Cardiology and Clinical ExaminationFaculty of MedicineOita UniversityOitaJapan
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Sinno MC, Carrigan T, Hays JC. Caudocranial transseptal approach for placement of endocardial left ventricular leads. J Cardiovasc Electrophysiol 2020; 31:2216-2221. [PMID: 32608150 DOI: 10.1111/jce.14644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 06/02/2020] [Accepted: 06/21/2020] [Indexed: 11/30/2022]
Abstract
Cardiac resynchronization therapy (CRT) is associated with improvement in the quality of life, hospitalization rates, and mortality in patients with left ventricular dysfunction and evidence of the right ventricle-left ventricle (RV-LV) desynchrony. Implant failure rates and patient outcomes have improved with the advent of quadripolar leads, yet alternatives to traditional coronary sinus (CS) LV lead placement is sought for in a subset of advanced heart failure patients with difficult CS anatomy, phrenic nerve stimulation or in nonresponders. Endocardial left ventricular pacing (EnLVP) in chronically anticoagulated patients has been reported as an alternative using different approaches, techniques, and tools with acceptable short and long term adverse events. We present a case of successful EnLVP achieved for CRT using standard techniques and commonly available tools in a patient on chronic direct oral anticoagulation with recurrent heart failure admissions who failed traditional epicardial LV pacing.
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Affiliation(s)
- Mohamad C Sinno
- Department of Cardiac Electrophysiology, Heart and Vascular Institute, St Elizabeth Healthcare, Edgewood, Kentucky
| | - Thomas Carrigan
- Department of Cardiac Electrophysiology, Heart and Vascular Institute, St Elizabeth Healthcare, Edgewood, Kentucky
| | - J Christian Hays
- Department of Cardiac Electrophysiology, Heart and Vascular Institute, St Elizabeth Healthcare, Edgewood, Kentucky
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12
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Ho CY, Olivotto I, Jacoby D, Lester SJ, Roe M, Wang A, Waldman CB, Zhang D, Sehnert AJ, Heitner SB. Study Design and Rationale of EXPLORER-HCM: Evaluation of Mavacamten in Adults With Symptomatic Obstructive Hypertrophic Cardiomyopathy. Circ Heart Fail 2020; 13:e006853. [PMID: 32498620 DOI: 10.1161/circheartfailure.120.006853] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Obstructive hypertrophic cardiomyopathy (oHCM) is characterized by unexplained left ventricular (LV) hypertrophy associated with dynamic LV outflow tract obstruction. Current medical therapies are nonspecific and have limited efficacy in relieving symptoms. Mavacamten is a first-in-class targeted inhibitor of cardiac myosin, which has been shown to reduce LV outflow tract obstruction, improve exercise capacity, and relieve symptoms of oHCM in the PIONEER-HCM phase 2 study. METHODS EXPLORER-HCM is a multicenter, phase 3, randomized, double-blind, placebo-controlled trial to investigate the efficacy and safety of mavacamten in treating symptomatic oHCM. Eligible adults with oHCM and New York Heart Association Functional Class II or III are randomized 1:1 to receive once-daily, oral mavacamten, or matching placebo for 30 weeks. The primary composite functional end point is clinical response at week 30 compared to baseline defined as either (1) an increase in peak oxygen consumption ≥1.5 mL/kg/min and reduction of at least one New York Heart Association class; or (2) an improvement of ≥3.0 mL/kg/min in peak oxygen consumption with no worsening of New York Heart Association class. Secondary end points include change in postexercise LV outflow tract gradient, New York Heart Association class, peak oxygen consumption, and patient-reported outcomes assessed by the Kansas City Cardiomyopathy Questionnaire and a novel HCM-specific instrument. Exploratory end points aim to characterize the effect of mavacamten on multiple aspects of oHCM pathophysiology. CONCLUSIONS EXPLORER-HCM is a phase 3 trial in oHCM testing a first-in-class, targeted strategy of myosin inhibition to improve symptom burden and exercise capacity through reducing LV outflow tract obstruction. Results of this trial will provide evidence to support the first disease-specific treatment for HCM. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03470545.
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Affiliation(s)
- Carolyn Y Ho
- Brigham and Women's Hospital, Boston, MA (C.Y.H.)
| | | | | | | | - Matthew Roe
- Duke Clinical Research Institute, Durham, NC (M.R.)
| | - Andrew Wang
- Duke University School of Medicine, Durham, NC (A.W.)
| | | | | | | | - Stephen B Heitner
- Knight Cardiovascular Institute, Oregon Health and Sciences University, Portland (S.B.H.)
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Sau A, Howard JP, Al-Aidarous S, Ferreira-Martins J, Al-Khayatt B, Lim PB, Kanagaratnam P, Whinnett ZI, Peters NS, Sikkel MB, Francis DP, Sohaib SMA. Meta-Analysis of Randomized Controlled Trials of Atrial Fibrillation Ablation With Pulmonary Vein Isolation Versus Without. JACC Clin Electrophysiol 2019; 5:968-976. [PMID: 31439299 PMCID: PMC6709782 DOI: 10.1016/j.jacep.2019.05.012] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 04/15/2019] [Accepted: 05/17/2019] [Indexed: 01/09/2023]
Abstract
Objectives This meta-analysis examined the ability of pulmonary vein isolation (PVI) to prevent atrial fibrillation in randomized controlled trials (RCTs) in which the patients not receiving PVI nevertheless underwent a procedure. Background PVI is a commonly used procedure for the treatment of atrial fibrillation (AF), and its efficacy has usually been judged against therapy with anti-arrhythmic drugs in open-label trials. There have been several RCTs of AF ablation in which both arms received an ablation, but the difference between the treatment arms was inclusion or omission of PVI. These trials of an ablation strategy with PVI versus an ablation strategy without PVI may provide a more rigorous method for evaluating the efficacy of PVI. Methods Medline and Cochrane databases were searched for RCTs comparing ablation including PVI with ablation excluding PVI. The primary efficacy endpoint was freedom from atrial fibrillation (AF) and atrial tachycardia at 12 months. A random-effects meta-analysis was performed using the restricted maximum likelihood estimator. Results Overall, 6 studies (n = 610) met inclusion criteria. AF recurrence was significantly lower with an ablation including PVI than an ablation without PVI (RR: 0.54; 95% confidence interval [CI]: 0.33 to 0.89; p = 0.0147; I2 = 79.7%). Neither the type of AF (p = 0.48) nor the type of non-PVI ablation (p = 0.21) was a significant moderator of the effect size. In 3 trials the non-PVI ablation procedure was performed in both arms, whereas PVI was performed in only 1 arm. In these studies, AF recurrence was significantly lower when PVI was included (RR: 0.32; 95% CI: 0.14 to 0.73; p = 0.007, I2 78%). Conclusions In RCTs where both arms received an ablation, and therefore an expectation amongst patients and doctors of benefit, being randomized to PVI had a striking effect, reducing AF recurrence by a half.
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Affiliation(s)
- Arunashis Sau
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - James P Howard
- National Heart and Lung Institute, Imperial College London, London, United Kingdom; Department of Cardiology, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom
| | - Sayed Al-Aidarous
- National Heart and Lung Institute, Imperial College London, London, United Kingdom; Department of Cardiology, Royal Brompton and Harefield NHS Foundation Trust, London, United Kingdom
| | | | - Becker Al-Khayatt
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - P Boon Lim
- National Heart and Lung Institute, Imperial College London, London, United Kingdom; Department of Cardiology, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom
| | - Prapa Kanagaratnam
- National Heart and Lung Institute, Imperial College London, London, United Kingdom; Department of Cardiology, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom
| | - Zachary I Whinnett
- National Heart and Lung Institute, Imperial College London, London, United Kingdom; Department of Cardiology, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom
| | - Nicholas S Peters
- National Heart and Lung Institute, Imperial College London, London, United Kingdom; Department of Cardiology, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom
| | - Markus B Sikkel
- National Heart and Lung Institute, Imperial College London, London, United Kingdom; Department of Cardiology, Royal Jubilee Hospital, Victoria, Canada
| | - Darrel P Francis
- National Heart and Lung Institute, Imperial College London, London, United Kingdom; Department of Cardiology, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom
| | - S M Afzal Sohaib
- National Heart and Lung Institute, Imperial College London, London, United Kingdom; Department of Cardiac Electrophysiology, Bart's Heart Centre, St Bartholomew's Hospital, London, United Kingdom; Department of Cardiology, King George Hospital, Ilford, United Kingdom.
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Multicenter prospective observational long-term follow-up study of endocardial cardiac resynchronization therapy using the Jurdham procedure. Heart Rhythm 2019; 16:1453-1461. [PMID: 31323347 DOI: 10.1016/j.hrthm.2019.07.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Indexed: 11/22/2022]
Abstract
BACKGROUND Endocardial cardiac resynchronization therapy (eCRT) avoids the limitations and failures of coronary sinus (CS) resynchronization. However, data regarding long-term outcomes are lacking. OBJECTIVE The purpose of this study was to report the long-term outcome of eCRT performed using the Jurdham procedure in a real-world setting. METHODS eCRT was performed in patients who failed a CS implant or failed to respond to cardiac resynchronization therapy (CRT), or in selected patients requiring lifelong oral anticoagulation (OAC). Left ventricular ejection fraction (LVEF), New York Heart Association functional class (NYHA FC), and left ventricular stimulation parameters were assessed during long-term follow-up (FU). RESULTS From August 2009 to March 2018, the Jurdham procedure was performed in 88 patients at 15 centers in 8 countries, with FU of 32.88 ± 61.52 months (range 0-88 months; 196 patient-years). NYHA FC improved from 2.9 preimplant to 1.3 during FU. LVEF increased <10 percentage points from baseline in 7% of patients, between 10 and 20 percentage points in 11% of patients, and >20 percentage points in 82% of patients. All-cause mortality at 60 months was 30.5%. Three transient ischemic attacks (1.53 per 100 patient-years) and 6 strokes (3.06 per 100 patient-years) occurred. Of the 6 patients with stroke, 4 (66%) had almost complete recovery. CONCLUSION eCRT using the Jurdham procedure is an effective and safe technique in anticoagulated patients. This approach may be an attractive option for patients with failed CS implants or nonresponders to CS CRT. In addition, it might be a reasonable approach as a first option for treatment of patients requiring lifelong OAC.
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15
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Renal sympathetic denervation for treatment of hypertension: where are we now in 2019? Curr Opin Nephrol Hypertens 2019; 28:498-506. [PMID: 31268917 DOI: 10.1097/mnh.0000000000000532] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
PURPOSE OF REVIEW Although sound physiological principles and surgical precedent underpin renal denervation as a therapy for treatment resistant hypertension, and early clinical studies had produced encouraging results, the first sham-controlled study (SYMPLICITY HTN-3) failed to achieve its primary efficacy endpoint. Lessons learnt from this trial, and the knowledge derived from further animal and autopsy work, have been applied in three recently published sham-controlled trials. RECENT FINDINGS These trials - SPYRAL OFF-MED, RADIANCE SOLO and SPYRAL ON-MED - using newer technologies, demonstrate a 5-10 mmHg incremental reduction in ambulatory SBP from RDN against sham-control, in patients with mild-to-moderate hypertension taking 0-3 drugs. SUMMARY These results provide proof of principle of the blood pressure-lowering effect of renal denervation. We now require data on long-term safety and durability of the procedure. Research is needed to identify predictive markers of response as about one-third of individuals do not respond to renal denervation. Hard-outcome data would be welcome but might be difficult to acquire. Individuals with treatment resistance are obvious treatment candidates, but RDN may also potentially benefit those with medication nonadherence and/or intolerance and those unwilling to take pills.
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Arnold AD, Shun-Shin MJ, Keene D, Howard JP, Sohaib SMA, Wright IJ, Cole GD, Qureshi NA, Lefroy DC, Koa-Wing M, Linton NWF, Lim PB, Peters NS, Davies DW, Muthumala A, Tanner M, Ellenbogen KA, Kanagaratnam P, Francis DP, Whinnett ZI. His Resynchronization Versus Biventricular Pacing in Patients With Heart Failure and Left Bundle Branch Block. J Am Coll Cardiol 2018; 72:3112-3122. [PMID: 30545450 PMCID: PMC6290113 DOI: 10.1016/j.jacc.2018.09.073] [Citation(s) in RCA: 165] [Impact Index Per Article: 27.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Revised: 09/11/2018] [Accepted: 09/13/2018] [Indexed: 11/05/2022]
Abstract
BACKGROUND His bundle pacing is a new method for delivering cardiac resynchronization therapy (CRT). OBJECTIVES The authors performed a head-to-head, high-precision, acute crossover comparison between His bundle pacing and conventional biventricular CRT, measuring effects on ventricular activation and acute hemodynamic function. METHODS Patients with heart failure and left bundle branch block referred for conventional biventricular CRT were recruited. Using noninvasive epicardial electrocardiographic imaging, the authors identified patients in whom His bundle pacing shortened left ventricular activation time. In these patients, the authors compared the hemodynamic effects of His bundle pacing against biventricular pacing using a high-multiple repeated alternation protocol to minimize the effect of noise, as well as comparing effects on ventricular activation. RESULTS In 18 of 23 patients, left ventricular activation time was significantly shortened by His bundle pacing. Seventeen patients had a complete electromechanical dataset. In them, His bundle pacing was more effective at delivering ventricular resynchronization than biventricular pacing: greater reduction in QRS duration (-18.6 ms; 95% confidence interval [CI]: -31.6 to -5.7 ms; p = 0.007), left ventricular activation time (-26 ms; 95% CI: -41 to -21 ms; p = 0.002), and left ventricular dyssynchrony index (-11.2 ms; 95% CI: -16.8 to -5.6 ms; p < 0.001). His bundle pacing also produced a greater acute hemodynamic response (4.6 mm Hg; 95% CI: 0.2 to 9.1 mm Hg; p = 0.04). The incremental activation time reduction with His bundle pacing over biventricular pacing correlated with the incremental hemodynamic improvement with His bundle pacing over biventricular pacing (R = 0.70; p = 0.04). CONCLUSIONS His resynchronization delivers better ventricular resynchronization, and greater improvement in hemodynamic parameters, than biventricular pacing.
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Affiliation(s)
- Ahran D Arnold
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Matthew J Shun-Shin
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Daniel Keene
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - James P Howard
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - S M Afzal Sohaib
- National Heart and Lung Institute, Imperial College London, London, United Kingdom; St. Bartholomew's Hospital, London, United Kingdom
| | - Ian J Wright
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Graham D Cole
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Norman A Qureshi
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - David C Lefroy
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Michael Koa-Wing
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Nick W F Linton
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Phang Boon Lim
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Nicholas S Peters
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - D Wyn Davies
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Amal Muthumala
- St. Bartholomew's Hospital, London, United Kingdom; North Middlesex Hospital NHS Trust, London, United Kingdom
| | - Mark Tanner
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | | | - Prapa Kanagaratnam
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Darrel P Francis
- National Heart and Lung Institute, Imperial College London, London, United Kingdom.
| | - Zachary I Whinnett
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
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Koyak Z, de Groot JR, Krimly A, Mackay TM, Bouma BJ, Silversides CK, Oechslin EN, Hoke U, van Erven L, Budts W, Van Gelder IC, Mulder BJM, Harris L. Cardiac resynchronization therapy in adults with congenital heart disease. Europace 2018; 20:315-322. [PMID: 28108550 DOI: 10.1093/europace/euw386] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2016] [Accepted: 11/02/2016] [Indexed: 11/14/2022] Open
Abstract
Aims In adults with congenital heart disease (CHD) heart failure is one of the leading causes of morbidity and mortality but experience with and reported outcome of cardiac resynchronization therapy (CRT) is limited. We investigated the efficacy of CRT in adults with CHD. Methods and results This was a retrospective study including 48 adults with CHD who received CRT since 2003 in four tertiary referral centres. Responders were defined as patients who showed improvement in NYHA functional class and/or systemic ventricular ejection fraction by at least one category. Ventricular function was assessed by echocardiography and graded on a four point ordinal scale. Median age at CRT was 47 years (range 18-74 years) and 77% was male. Cardiac diagnosis included tetralogy of Fallot in 29%, (congenitally corrected) transposition of great arteries in 23%, septal defects in 25%, left sided lesions in 21%, and Marfan syndrome in 2% of the patients. The median follow-up duration after CRT was 2.6 years (range 0.1-8.8). Overall, 37 out of 48 patients (77%) responded to CRT either by improvement of NYHA functional class and/or systemic ventricular function. There were 11 non-responders to CRT. Of these, three patients died and four underwent heart transplantation. Conclusion In this cohort of older CHD patients, CRT was accomplished with a success rate comparable to those with acquired heart disease despite the complex anatomy and technical challenges frequently encountered in this population. Further studies are needed to establish appropriate guidelines for patient selection and long term outcome.
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Affiliation(s)
- Zeliha Koyak
- Department of Cardiology, Academic Medical Center Amsterdam, The Netherlands.,Interuniversity Cardiology Institute of the Netherlands, Utrecht, The Netherlands
| | - Joris R de Groot
- Department of Cardiology, Academic Medical Center Amsterdam, The Netherlands
| | - Ahmed Krimly
- Division of Cardiology, Peter Munk Cardiac Center, Toronto Congenital Cardiac Center for Adults, and University of Toronto, Toronto, Canada
| | - Tara M Mackay
- Department of Cardiology, Academic Medical Center Amsterdam, The Netherlands
| | - Berto J Bouma
- Department of Cardiology, Academic Medical Center Amsterdam, The Netherlands
| | - Candice K Silversides
- Division of Cardiology, Peter Munk Cardiac Center, Toronto Congenital Cardiac Center for Adults, and University of Toronto, Toronto, Canada
| | - Erwin N Oechslin
- Division of Cardiology, Peter Munk Cardiac Center, Toronto Congenital Cardiac Center for Adults, and University of Toronto, Toronto, Canada
| | - Ulas Hoke
- Leiden University Medical Center, Leiden, The Netherlands
| | | | - Werner Budts
- Department of Cardiology, UZ Leuven, Leuven, Belgium
| | - Isabelle C Van Gelder
- Department of Cardiology, University Medical Center Groningen, Groningen, The Netherlands
| | - Barbara J M Mulder
- Department of Cardiology, Academic Medical Center Amsterdam, The Netherlands.,Interuniversity Cardiology Institute of the Netherlands, Utrecht, The Netherlands
| | - Louise Harris
- Division of Cardiology, Peter Munk Cardiac Center, Toronto Congenital Cardiac Center for Adults, and University of Toronto, Toronto, Canada
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Butter C, Fehrendt S, Möller V, Seifert M. [Leadless endocardial ultrasound based left ventricular stimulation : WISE CRT System: alternative to conventional methods]. Herzschrittmacherther Elektrophysiol 2018; 29:340-348. [PMID: 30406825 DOI: 10.1007/s00399-018-0605-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Accepted: 09/10/2018] [Indexed: 02/03/2023]
Abstract
There are still several limitations in delivering cardiac resynchronisation therapy (CRT). After 6 months, 20-40% of patients fail to have clinical benefit due to various reasons. Endocardial stimulation rather than conventional epicardial pacing has been shown to be more physiological, improves electrical stimulation of the left ventricle (LV), has less dispersion of electrical activity and results in better resynchronisation. The WiSE™ CRT System ("Wireless stimulation endocardial system"; EBR Systems, Sunnyvale, CA, USA) provides an option for wireless, LV endocardial pacing triggered by a conventional right ventricular pacing spike from a co-implant. The feasibility of the WiSE™ CRT System has been successfully demonstrated in a population of failed cardiac resynchronisation patients with either failed implantation of a conventional system, nonresponse to conventional therapy or upgrade from pacemaker or defibrillator, where a conventional system was not an option. The WiSE™ CRT System is an innovative technology with promising safety, performance and preliminary efficacy.
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Affiliation(s)
- C Butter
- Immanuel Klinikum Bernau und Herzzentrum Brandenburg, Abteilung für Kardiologie, Hochschulklinikum der Medizinischen Hochschule Brandenburg, Ladeburger Straße 17, 16321, Bernau, Deutschland.
| | - S Fehrendt
- Immanuel Klinikum Bernau und Herzzentrum Brandenburg, Abteilung für Kardiologie, Hochschulklinikum der Medizinischen Hochschule Brandenburg, Ladeburger Straße 17, 16321, Bernau, Deutschland
| | - V Möller
- Immanuel Klinikum Bernau und Herzzentrum Brandenburg, Abteilung für Kardiologie, Hochschulklinikum der Medizinischen Hochschule Brandenburg, Ladeburger Straße 17, 16321, Bernau, Deutschland
| | - M Seifert
- Immanuel Klinikum Bernau und Herzzentrum Brandenburg, Abteilung für Kardiologie, Hochschulklinikum der Medizinischen Hochschule Brandenburg, Ladeburger Straße 17, 16321, Bernau, Deutschland
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Vader JM, Cooper DH, Rao P. Re-Thinking Re-Synching in Left Ventricular Assist Device Recipients. J Am Heart Assoc 2018; 7:JAHA.118.009591. [PMID: 29907653 PMCID: PMC6220548 DOI: 10.1161/jaha.118.009591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
| | | | - Praveen Rao
- Baylor University Medical Center, Dallas, TX
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20
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Papageorgiou N, Providência R, Lambiase PD, Tousoulis D, Lloyd G, Bhattacharyya S. Does presence of left ventricular contractile reserve improve response to cardiac resynchronization therapy? An updated meta-analysis. Int J Cardiol 2018; 252:224-228. [DOI: 10.1016/j.ijcard.2017.09.034] [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: 05/03/2017] [Revised: 07/26/2017] [Accepted: 09/12/2017] [Indexed: 10/18/2022]
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Ali N, Keene D, Arnold A, Shun-Shin M, Whinnett ZI, Afzal Sohaib SM. His Bundle Pacing: A New Frontier in the Treatment of Heart Failure. Arrhythm Electrophysiol Rev 2018; 7:103-110. [PMID: 29967682 DOI: 10.15420/aer.2018.6.2] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Biventricular pacing has revolutionised the treatment of heart failure in patients with sinus rhythm and left bundle branch block; however, left ventricular-lead placement is not always technically possible. Furthermore, biventricular pacing does not fully normalise ventricular activation and, therefore, the ventricular resynchronisation is imperfect. Right ventricular pacing for bradycardia may cause or worsen heart failure in some patients by causing dyssynchronous ventricular activation. His bundle pacing activates the ventricles via the native His-Purkinje system, resulting in true physiological pacing, and, therefore, is a promising alternate site for pacing in bradycardia and traditional CRT indications in cases where it can overcome left bundle branch block. Furthermore, it may open up new indications for pacing therapy in heart failure, such as targeting patients with PR prolongation, but a narrow QRS duration. In this article we explore the physiology, technology and potential roles of His bundle pacing in the prevention and treatment of heart failure.
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Affiliation(s)
- Nadine Ali
- National Heart and Lung Institute, Imperial College London, UK
| | - Daniel Keene
- National Heart and Lung Institute, Imperial College London, UK
| | - Ahran Arnold
- National Heart and Lung Institute, Imperial College London, UK
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22
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The Placebo Effect in Cardiology: Understanding and Using It. Can J Cardiol 2017; 33:1535-1542. [DOI: 10.1016/j.cjca.2017.09.017] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Revised: 09/28/2017] [Accepted: 09/28/2017] [Indexed: 12/18/2022] Open
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Affiliation(s)
- Anoop K. Shetty
- From the Department of Cardiology, Guy’s and St. Thomas’ NHS Foundation Trust, and The Division of Imaging Sciences and Biomedical Engineering, King’s College London, United Kingdom
| | - Christopher A. Rinaldi
- From the Department of Cardiology, Guy’s and St. Thomas’ NHS Foundation Trust, and The Division of Imaging Sciences and Biomedical Engineering, King’s College London, United Kingdom
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Gamble JHP, Herring N, Ginks M, Rajappan K, Bashir Y, Betts TR. Endocardial left ventricular pacing for cardiac resynchronization: systematic review and meta-analysis. Europace 2017; 20:73-81. [DOI: 10.1093/europace/euw381] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Accepted: 10/31/2016] [Indexed: 11/14/2022] Open
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Morgan JM, Wiles BM. Is Left Ventricular Endocardial Pacing the Future for Cardiac Resynchronization Therapy? REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2017; 70:14-15. [PMID: 27825719 DOI: 10.1016/j.rec.2016.06.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/25/2016] [Accepted: 06/14/2016] [Indexed: 06/06/2023]
Affiliation(s)
- John M Morgan
- Cardiac Rhythm Management Department, Faculty of Medicine, University of Southampton, Southampton, United Kingdom; Cardiac Rhythm Management Department (Europe), Boston Scientific, Hemel Hempstead, Hertfordshire, United Kingdom.
| | - Benedict M Wiles
- Cardiac Rhythm Management Department, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
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26
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Morgan JM, Wiles BM. ¿El marcapasos endocárdico ventricular izquierdo es el futuro de la terapia de resincronización cardiaca? Rev Esp Cardiol (Engl Ed) 2017. [DOI: 10.1016/j.recesp.2016.06.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Seifert M, Butter C. Evaluation of wireless stimulation of the endocardium, WiSE, technology for treatment heart failure. Expert Rev Med Devices 2016; 13:523-31. [DOI: 10.1080/17434440.2016.1187559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Sohaib SMA, Wright I, Lim E, Moore P, Lim PB, Koawing M, Lefroy DC, Lusgarten D, Linton NWF, Davies DW, Peters NS, Kanagaratnam P, Francis DP, Whinnett ZI. Atrioventricular Optimized Direct His Bundle Pacing Improves Acute Hemodynamic Function in Patients With Heart Failure and PR Interval Prolongation Without Left Bundle Branch Block. JACC Clin Electrophysiol 2015; 1:582-591. [PMID: 29759412 DOI: 10.1016/j.jacep.2015.08.008] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2015] [Accepted: 08/27/2015] [Indexed: 11/15/2022]
Abstract
OBJECTIVES The purpose of this study was to investigate whether heart failure patients with narrow QRS duration (or right bundle branch block) but with long PR interval gain acute hemodynamic benefit from atrioventricular (AV) optimization. We tested this with biventricular pacing and (to deliver pure AV shortening) direct His bundle pacing. BACKGROUND Benefits of pacing for heart failure have previously been indicated by acute hemodynamic studies and verified in outcome studies. A new target for pacing in heart failure may be PR interval prolongation, which is associated with 58% higher mortality regardless of QRS duration. METHODS We enrolled 16 consecutive patients with systolic heart failure, PR interval prolongation (mean, 254 ± 62 ms) and narrow QRS duration (n = 13; mean QRS duration: 119 ± 17 ms) or right bundle branch block (n = 3; mean, QRS duration: 156 ± 18 ms). We successfully delivered temporary direct His bundle pacing in 14 patients and temporary biventricular pacing in 14 participants. We performed AV optimization using invasive systolic blood pressure obtaining parabolic responses (mean R2: 0.90 for His, and 0.85 for biventricular pacing). RESULTS The mean increment in systolic BP compared with intrinsic ventricular conduction was 4.1 mm Hg (95% confidence interval [CI]: +1.9 to +6.2 mm Hg for His and 4.3 mm Hg [95% CI: +2.0 to +6.5 mm Hg] for biventricular pacing. QRS duration lengthened with biventricular pacing (change = +22 ms [95% CI: +18 to +25 ms]) but not with His pacing (change = +0.5 ms [95% CI: -2.6 to +3.6 ms). CONCLUSIONS AV-optimized pacing improves acute hemodynamic function in patients with heart failure and long PR interval without left bundle branch block. That it can be achieved by single-site His pacing shows that its mechanism is AV shortening. The improvement is ∼60% of the effect size previously reported for biventricular pacing in left bundle branch block. Randomized, blinded trials are warranted to test for long-term beneficial effects.
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Affiliation(s)
- S M Afzal Sohaib
- National Heart & Lung Institute, Imperial College London, London, United Kingdom
| | - Ian Wright
- Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom
| | - Elaine Lim
- Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom
| | - Philip Moore
- Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom
| | - P Boon Lim
- Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom
| | - Michael Koawing
- Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom
| | - David C Lefroy
- Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom
| | - Daniel Lusgarten
- Department of Medicine, University of Vermont College of Medicine, Burlington, Vermont
| | - Nick W F Linton
- National Heart & Lung Institute, Imperial College London, London, United Kingdom
| | - D Wyn Davies
- Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom
| | - Nicholas S Peters
- National Heart & Lung Institute, Imperial College London, London, United Kingdom
| | - Prapa Kanagaratnam
- Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom
| | - Darrel P Francis
- National Heart & Lung Institute, Imperial College London, London, United Kingdom.
| | - Zachary I Whinnett
- National Heart & Lung Institute, Imperial College London, London, United Kingdom; Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom
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Linde C, Curtis AB, Fonarow GC, Lee K, Little W, Tang A, Levya F, Momomura SI, Manrodt C, Bergemann T, Cowie MR. Cardiac resynchronization therapy in chronic heart failure with moderately reduced left ventricular ejection fraction: Lessons from the Multicenter InSync Randomized Clinical Evaluation MIRACLE EF study. Int J Cardiol 2015; 202:349-55. [PMID: 26426276 DOI: 10.1016/j.ijcard.2015.09.023] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2015] [Revised: 06/15/2015] [Accepted: 09/19/2015] [Indexed: 01/14/2023]
Abstract
BACKGROUND The benefits of CRT for symptomatic heart failure (HF) patients with a wide QRS and reduced left ventricular ejection fraction (LVEF≤35%), are well established .Post-hoc subgroup analyses suggest that CRT benefit may extend to patients with LVEF>35%. METHODS The MIRACLE EF was a prospective, randomized, controlled, double-blinded study to evaluate CRT-P in NYHA II-III HF patients with LBBB and with LVEF of 36%-50% and no previous pacing or ICD. The primary endpoint was a composite of time to first HF event or death. All patients were implanted with a CRT-P and randomized 2:1 to CRT-P ON or CRT-P OFF groups. The minimum follow up time was 24 months. RESULTS The MIRACLE EF study was stopped for enrollment futility after 13 months and enrolling only 44 patients. The main difficulties in recruiting patients were lack of eligible patients, previous ICD implants, and the reluctance of institutions, patients or physicians to enroll in the study which included a potential 5 year CRT OFF period. CONCLUSION Despite a careful design, identification and randomization of eligible patients were challenging and a trial to assess morbidity and mortality trial was not feasible. The MIRACLE EF experience illustrates the difficulties of designing a scientifically robust but feasible study to assess potential new indications for implantable devices. Smaller randomized studies with surrogate endpoints may therefore be more reasonable, although the potential impact of such studies on clinical practice, guidelines, and reimbursement remain to be determined.
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Affiliation(s)
| | | | | | - Kerry Lee
- Duke Clinical Research Institute, Durham, NC, United States
| | | | | | | | | | | | | | - Martin R Cowie
- Imperial College London, The Royal Brompton Hospital, London, United Kingdom
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Abstract
Cardiac resynchronisation therapy (CRT) is an effective intervention for appropriately selected patients with heart failure, but exactly how it works is uncertain. Recent data suggest that much, or perhaps most, of the benefits of CRT are not delivered by re-coordinating left ventricular dyssynchrony. Atrio-ventricular resynchronization, reduction in mitral regurgitation and prevention of bradycardia are other potential mechanisms of benefit that will vary from one patient to the next and over time. Because there is no single therapeutic target, it is unlikely that any single measure will accurately predict benefit. The only clinical characteristic that appears to be a useful predictor of the benefits of CRT is a QRS duration of >140 ms. Many new approaches are being developed to try to improve the effectiveness of and extend the indications for CRT. These include smart pacing algorithms, better pacing-site targeting, new sensors, multipoint pacing, remote device monitoring and leadless endocardial pacing. Whether CRT is effective in patients with atrial fibrillation or whether adding a defibrillator function to CRT improves prognosis awaits further evidence.
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Bernard A, Donal E, Leclercq C, Schnell F, Fournet M, Reynaud A, Thebault C, Mabo P, Daubert JC, Hernandez A. Impact of Cardiac Resynchronization Therapy on Left Ventricular Mechanics: Understanding the Response through a New Quantitative Approach Based on Longitudinal Strain Integrals. J Am Soc Echocardiogr 2015; 28:700-8. [DOI: 10.1016/j.echo.2015.02.017] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2014] [Indexed: 10/23/2022]
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Sohaib SMA, Kyriacou A, Jones S, Manisty CH, Mayet J, Kanagaratnam P, Peters NS, Hughes AD, Whinnett ZI, Francis DP. Evidence that conflict regarding size of haemodynamic response to interventricular delay optimization of cardiac resynchronization therapy may arise from differences in how atrioventricular delay is kept constant. Europace 2015; 17:1823-33. [PMID: 25855674 PMCID: PMC4700730 DOI: 10.1093/europace/euu374] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2014] [Accepted: 12/01/2014] [Indexed: 01/21/2023] Open
Abstract
Aims Whether adjusting interventricular (VV) delay changes haemodynamic efficacy of cardiac resynchronization therapy (CRT) is controversial, with conflicting results. This study addresses whether the convention for keeping atrioventricular (AV) delay constant during VV optimization might explain these conflicts. Method and results Twenty-two patients in sinus rhythm with existing CRT underwent VV optimization using non-invasive systolic blood pressure. Interventricular optimization was performed with four methods for keeping the AV delay constant: (i) atrium and left ventricle delay kept constant, (ii) atrium and right ventricle delay kept constant, (iii) time to the first-activated ventricle kept constant, and (iv) time to the second-activated ventricle kept constant. In 11 patients this was performed with AV delay of 120 ms, and in 11 at AV optimum. At AV 120 ms, time to the first ventricular lead (left or right) was the overwhelming determinant of haemodynamics (13.75 mmHg at ±80 ms, P < 0.001) with no significant effect of time to second lead (0.47 mmHg, P = 0.50), P < 0.001 for difference. At AV optimum, time to first ventricular lead again had a larger effect (5.03 mmHg, P < 0.001) than time to second (2.92 mmHg, P = 0.001), P = 0.02 for difference. Conclusion Time to first ventricular activation is the overwhelming determinant of circulatory function, regardless of whether this is the left or right ventricular lead. If this is kept constant, the effect of changing time to the second ventricle is small or nil, and is not beneficial. In practice, it may be advisable to leave VV delay at zero. Specifying how AV delay is kept fixed might make future VV delay research more enlightening.
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Affiliation(s)
- S M Afzal Sohaib
- International Centre for Circulatory Health, Imperial College London, 59-61 North Wharf Road, London W2 1LA, UK
| | - Andreas Kyriacou
- International Centre for Circulatory Health, Imperial College London, 59-61 North Wharf Road, London W2 1LA, UK
| | - Siana Jones
- International Centre for Circulatory Health, Imperial College London, 59-61 North Wharf Road, London W2 1LA, UK
| | - Charlotte H Manisty
- International Centre for Circulatory Health, Imperial College London, 59-61 North Wharf Road, London W2 1LA, UK
| | - Jamil Mayet
- International Centre for Circulatory Health, Imperial College London, 59-61 North Wharf Road, London W2 1LA, UK
| | - Prapa Kanagaratnam
- International Centre for Circulatory Health, Imperial College London, 59-61 North Wharf Road, London W2 1LA, UK
| | - Nicholas S Peters
- International Centre for Circulatory Health, Imperial College London, 59-61 North Wharf Road, London W2 1LA, UK
| | - Alun D Hughes
- International Centre for Circulatory Health, Imperial College London, 59-61 North Wharf Road, London W2 1LA, UK
| | - Zachary I Whinnett
- International Centre for Circulatory Health, Imperial College London, 59-61 North Wharf Road, London W2 1LA, UK
| | - Darrel P Francis
- International Centre for Circulatory Health, Imperial College London, 59-61 North Wharf Road, London W2 1LA, UK
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Sohaib SA, Finegold JA, Nijjer SS, Hossain R, Linde C, Levy WC, Sutton R, Kanagaratnam P, Francis DP, Whinnett ZI. Opportunity to Increase Life Span in Narrow QRS Cardiac Resynchronization Therapy Recipients by Deactivating Ventricular Pacing. JACC-HEART FAILURE 2015; 3:327-36. [DOI: 10.1016/j.jchf.2014.11.007] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/18/2014] [Revised: 11/12/2014] [Accepted: 11/14/2014] [Indexed: 01/14/2023]
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Witt CT, Kronborg MB, Nohr EA, Mortensen PT, Gerdes C, Nielsen JC. Optimization of heart failure medication after cardiac resynchronization therapy and the impact on long-term survival. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2015; 1:182-8. [DOI: 10.1093/ehjcvp/pvv016] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/05/2015] [Accepted: 03/25/2015] [Indexed: 11/15/2022]
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Overcoming the three biases obscuring the science of renal denervation in humans: Big-day bias, check-once-more bias and I-will-take-it-now bias. Trends Cardiovasc Med 2015; 25:116-8. [DOI: 10.1016/j.tcm.2014.10.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2014] [Accepted: 10/14/2014] [Indexed: 11/23/2022]
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Rosen MR, Myerburg RJ, Francis DP, Cole GD, Marbán E. Translating stem cell research to cardiac disease therapies: pitfalls and prospects for improvement. J Am Coll Cardiol 2014; 64:922-37. [PMID: 25169179 PMCID: PMC4209166 DOI: 10.1016/j.jacc.2014.06.1175] [Citation(s) in RCA: 72] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2014] [Revised: 06/02/2014] [Accepted: 06/05/2014] [Indexed: 12/23/2022]
Abstract
Over the past 2 decades, there have been numerous stem cell studies focused on cardiac diseases, ranging from proof-of-concept to phase 2 trials. This series of papers focuses on the legacy of these studies and the outlook for future treatment of cardiac diseases with stem cell therapies. The first section by Drs. Rosen and Myerburg is an independent review that analyzes the basic science and translational strategies supporting the rapid advance of stem cell technology to the clinic, the philosophies behind them, trial designs, and means for going forward that may impact favorably on progress. The second and third sections were collected as responses to the initial section of this review. The commentary by Drs. Francis and Cole discusses the review by Drs. Rosen and Myerburg and details how trial outcomes can be affected by noise, poor trial design (particularly the absence of blinding), and normal human tendencies toward optimism and denial. The final, independent paper by Dr. Marbán takes a different perspective concerning the potential for positive impact of stem cell research applied to heart disease and future prospects for its clinical application. (Compiled by the JACC editors).
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Affiliation(s)
- Michael R Rosen
- Departments of Pharmacology and Pediatrics, Columbia University Medical Center, New York, New York.
| | - Robert J Myerburg
- Division of Cardiology, University of Miami, Miller School of Medicine, Miami, Florida
| | - Darrel P Francis
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London, London, United Kingdom.
| | - Graham D Cole
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London, London, United Kingdom
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King SB, Dickert NW, Miller FG. Learning From FAME: The Need for Sham Controls in Trials of Stable Coronary Disease. JACC Cardiovasc Interv 2014; 7:342-4. [DOI: 10.1016/j.jcin.2014.02.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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