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Iwawaki T, Inden Y, Yanagisawa S, Goto T, Kondo S, Tachi M, Hiramatsu K, Yamauchi R, Shimojo M, Tsuji Y, Murohara T. A Novel Liver Fibrosis Marker FIB-5 Index Predicted Response to Cardiac Resynchronization Therapy and Prognostic Outcomes in Patients With Heart Failure. Ann Noninvasive Electrocardiol 2024; 29:e70004. [PMID: 39101582 PMCID: PMC11299164 DOI: 10.1111/anec.70004] [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: 04/17/2024] [Revised: 07/09/2024] [Accepted: 07/22/2024] [Indexed: 08/06/2024] Open
Abstract
BACKGROUND The fibrosis-5 (FIB-5) index is a noninvasive marker for assessing the progression of liver fibrosis and predictor in patients with heart failure (HF). This study investigated the association between the FIB-5 index and response to cardiac resynchronization therapy (CRT) and evaluated its predictive value for prognosis. METHODS In total, 203 patients who underwent CRT/CRT-defibrillator (CRT-D) implantation were retrospectively included. The FIB-5 index was calculated using blood samples obtained before and after CRT/CRT-D. Response to CRT was defined as a relative reduction in left ventricular end-systolic volume of ≥15% 6 months after CRT/CRT-D. We compared the prognosis after CRT/CRT-D between the groups according to the FIB-5 index. RESULTS One hundred and twenty-three patients (61%) responded to CRT. The responder group demonstrated a significantly higher FIB-5 index than the nonresponder group (-2.76 ± 3.85 vs. -4.67 ± 3.29, p < 0.001). Receiver-operating characteristic analysis demonstrated that the area under the curve of the FIB-5 index was 0.660 with a cutoff value of -4.00 for responders. In multivariate analysis, FIB-5 index ≥ -4.00 was an independent predictor for CRT response (odds ratio: 3.665, p = 0.003), in addition to QRS duration ≥ 150 ms and echocardiographic dysynchrony. The FIB-5 index increased significantly after 6 months in the responder group but not in the nonresponder group. The FIB-5 index ≥ -4.00 group showed a significantly better prognosis for cardiac death, HF hospitalization, and composite endpoint than the FIB-5 index < -4.00 group. CONCLUSION The FIB-5 index in addition to classical predictors may be a useful marker for predicting response to CRT.
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Affiliation(s)
- Tomoya Iwawaki
- Department of CardiologyNagoya University Graduate School of MedicineNagoyaJapan
| | - Yasuya Inden
- Department of CardiologyNagoya University Graduate School of MedicineNagoyaJapan
| | - Satoshi Yanagisawa
- Department of CardiologyNagoya University Graduate School of MedicineNagoyaJapan
- Department of Advanced Cardiovascular TherapeuticsNagoya University Graduate School of MedicineNagoyaJapan
| | - Takayuki Goto
- Department of CardiologyNagoya University Graduate School of MedicineNagoyaJapan
| | - Shun Kondo
- Department of CardiologyNagoya University Graduate School of MedicineNagoyaJapan
| | - Masaya Tachi
- Department of CardiologyNagoya University Graduate School of MedicineNagoyaJapan
| | - Kei Hiramatsu
- Department of CardiologyNagoya University Graduate School of MedicineNagoyaJapan
| | - Ryota Yamauchi
- Department of CardiologyNagoya University Graduate School of MedicineNagoyaJapan
| | - Masafumi Shimojo
- Department of CardiologyNagoya University Graduate School of MedicineNagoyaJapan
| | - Yukiomi Tsuji
- Department of CardiologyNagoya University Graduate School of MedicineNagoyaJapan
| | - Toyoaki Murohara
- Department of CardiologyNagoya University Graduate School of MedicineNagoyaJapan
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2
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Craine A, Krishnamurthy A, Villongco CT, Vincent K, Krummen DE, Narayan SM, Kerckhoffs RCP, Omens JH, Contijoch F, McCulloch AD. Successful Cardiac Resynchronization Therapy Reduces Negative Septal Work in Patient-Specific Models of Dyssynchronous Heart Failure. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2024:2024.05.13.593804. [PMID: 38798676 PMCID: PMC11118505 DOI: 10.1101/2024.05.13.593804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2024]
Abstract
In patients with dyssynchronous heart failure (DHF), cardiac conduction abnormalities cause the regional distribution of myocardial work to be non-homogeneous. Cardiac resynchronization therapy (CRT) using an implantable, programmed biventricular pacemaker/defibrillator, can improve the synchrony of contraction between the right and left ventricles in DHF, resulting in reduced morbidity and mortality and increased quality of life. Since regional work depends on wall stress, which cannot be measured in patients, we used computational methods to investigate regional work distributions and their changes after CRT. We used three-dimensional multi-scale patient-specific computational models parameterized by anatomic, functional, hemodynamic, and electrophysiological measurements in eight patients with heart failure and left bundle branch block (LBBB) who received CRT. To increase clinical translatability, we also explored whether streamlined computational methods provide accurate estimates of regional myocardial work. We found that CRT increased global myocardial work efficiency with significant improvements in non-responders. Reverse ventricular remodeling after CRT was greatest in patients with the highest heterogeneity of regional work at baseline, however the efficacy of CRT was not related to the decrease in overall work heterogeneity or to the reduction in late-activated regions of high myocardial work. Rather, decreases in early-activated regions of myocardium performing negative myocardial work following CRT best explained patient variations in reverse remodeling. These findings were also observed when regional myocardial work was estimated using ventricular pressure as a surrogate for myocardial stress and changes in endocardial surface area as a surrogate for strain. These new findings suggest that CRT promotes reverse ventricular remodeling in human dyssynchronous heart failure by increasing regional myocardial work in early-activated regions of the ventricles, where dyssynchrony is specifically associated with hypoperfusion, late systolic stretch, and altered metabolic activity and that measurement of these changes can be performed using streamlined approaches.
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Affiliation(s)
- Amanda Craine
- Department of Bioengineering, University of California San Diego, La Jolla, CA 92093, USA
| | - Adarsh Krishnamurthy
- Department of Bioengineering, University of California San Diego, La Jolla, CA 92093, USA
- Department of Mechanical Engineering, Iowa State University, Ames, IA 50011, USA
| | | | - Kevin Vincent
- Department of Bioengineering, University of California San Diego, La Jolla, CA 92093, USA
| | - David E. Krummen
- Department of Medicine (Cardiology), University of California San Diego, CA 92093, USA
- US Department of Veterans Affairs San Diego Healthcare System, San Diego, CA 92161, USA
| | | | - Roy C. P. Kerckhoffs
- Department of Bioengineering, University of California San Diego, La Jolla, CA 92093, USA
| | - Jeffrey H. Omens
- Department of Bioengineering, University of California San Diego, La Jolla, CA 92093, USA
- Department of Medicine (Cardiology), University of California San Diego, CA 92093, USA
| | - Francisco Contijoch
- Department of Bioengineering, University of California San Diego, La Jolla, CA 92093, USA
- Department of Radiology, University of California San Diego, CA 92093, USA
| | - Andrew D. McCulloch
- Department of Bioengineering, University of California San Diego, La Jolla, CA 92093, USA
- Department of Medicine (Cardiology), University of California San Diego, CA 92093, USA
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3
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Impact of synchronized left ventricular pacing rate on risk for ventricular tachyarrhythmias after cardiac resynchronization therapy in patients with heart failure. J Interv Card Electrophysiol 2022; 65:239-249. [PMID: 35739437 DOI: 10.1007/s10840-022-01284-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2022] [Accepted: 06/16/2022] [Indexed: 10/17/2022]
Abstract
BACKGROUND The adaptive cardiac resynchronization therapy (aCRT) algorithm automatically produces synchronized left ventricular pacing (sLVP) with intrinsic atrioventricular conduction to improve clinical outcomes. However, relationship between sLVP percentage and risk for ventricular tachyarrhythmia (VT/VF) remains unclear. This study aimed to evaluate the clinical impact of sLVP rate on VT/VF occurrence. METHODS In total, 1,419 device interrogation data from 42 consecutive patients who underwent new aCRT device implantation were retrospectively analyzed. The primary endpoint was the first time VT/VF episode after aCRT device implantation. RESULTS During a median follow-up of 34 months, 15 patients had VT/VF episodes. Patients were divided into a high sLVP (the average sLVP percentage of ≥ 51.5%, n = 27) or low sLVP group (< 51.5%, n = 15). The high sLVP group had a significantly lower VT/VF incidence (22% vs. 60%; p = 0.014) and an independent predictor for VT/VF occurrence on multivariate analysis (hazard ratio 0.21; p = 0.007). LV ejection fraction improvements after 6 months (12.3 ± 8.7% vs. 2.8 ± 10.3%; p = 0.004) and 12 months (13.8 ± 9.3% vs. 6.2 ± 11.1%; p = 0.030) were significantly greater in the high sLVP group than in the low sLVP group. Age, PR interval, and left atrial diameter were significantly associated with the sLVP rate after aCRT. CONCLUSIONS Patients with high sLVP percentage after aCRT had lower long-term risk of VT/VF incidence with a favorable response to CRT. A synchronized pacing algorithm using intrinsic conduction may prevent malignant arrhythmias, as well as recover cardiac functions.
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4
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Gill J. Emerging Technologies in Electrophysiology: From Single Chamber to Biventricular Leadless Pacemakers. Cardiology 2022; 147:179-190. [PMID: 35038698 DOI: 10.1159/000521976] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Accepted: 12/31/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Transvenous pacemakers have been shown to improve quality of life and mortality in patients with bradycardia and cardiac conduction blocks. However, they possess inevitable drawbacks as they have a relatively high incidence of lead and device pocket-related complications. Therefore, leadless pacemakers have emerged as a solution to reduce the complications seen with conventional pacemakers. However, there have been no clinical trials to date comparing transvenous to leadless pacemakers. SUMMARY Currently, the Micra TPS or AV device has been approved for commercial use worldwide but is limited to single-chamber pacing with single or dual-chamber sensing. Although the leadless pacemaker, Nanostim, was initially promising, it has been recalled due to concerns of battery failures and is no longer approved in Europe. In addition, the lack of defibrillation capabilities with leadless pacemakers has been a limiting factor; therefore, a leadless pacemaker with the already approved subcutaneous cardioverter-defibrillator system is currently being studied in humans. Moreover, the WiSE-CRT device has been approved in Europe, with the capabilities for leadless cardiac resynchronization therapy (CRT), to provide CRT for patients with unsuitable coronary sinus anatomy. Furthermore, retrieval of leadless pacemakers has been an area of concern; however, clinic data has signaled towards safe extraction of these devices with minimal complications. Key messages: This review will encompass the current literature regarding clinical safety and outcomes of these novel leadless pacemakers and discuss the evolving technologies in the field of cardiac pacing.
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Affiliation(s)
- Jashan Gill
- Department of Medicine, Rosalind Franklin University of Medicine and Science, North Chicago, Illinois, USA
- Department of Medicine, Northwestern Medicine McHenry Hospital, McHenry, Illinois, USA
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5
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Khamzin S, Dokuchaev A, Bazhutina A, Chumarnaya T, Zubarev S, Lyubimtseva T, Lebedeva V, Lebedev D, Gurev V, Solovyova O. Machine Learning Prediction of Cardiac Resynchronisation Therapy Response From Combination of Clinical and Model-Driven Data. Front Physiol 2022; 12:753282. [PMID: 34970154 PMCID: PMC8712879 DOI: 10.3389/fphys.2021.753282] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 11/22/2021] [Indexed: 11/17/2022] Open
Abstract
Background: Up to 30–50% of chronic heart failure patients who underwent cardiac resynchronization therapy (CRT) do not respond to the treatment. Therefore, patient stratification for CRT and optimization of CRT device settings remain a challenge. Objective: The main goal of our study is to develop a predictive model of CRT outcome using a combination of clinical data recorded in patients before CRT and simulations of the response to biventricular (BiV) pacing in personalized computational models of the cardiac electrophysiology. Materials and Methods: Retrospective data from 57 patients who underwent CRT device implantation was utilized. Positive response to CRT was defined by a 10% increase in the left ventricular ejection fraction in a year after implantation. For each patient, an anatomical model of the heart and torso was reconstructed from MRI and CT images and tailored to ECG recorded in the participant. The models were used to compute ventricular activation time, ECG duration and electrical dyssynchrony indices during intrinsic rhythm and BiV pacing from the sites of implanted leads. For building a predictive model of CRT response, we used clinical data recorded before CRT device implantation together with model-derived biomarkers of ventricular excitation in the left bundle branch block mode of activation and under BiV stimulation. Several Machine Learning (ML) classifiers and feature selection algorithms were tested on the hybrid dataset, and the quality of predictors was assessed using the area under receiver operating curve (ROC AUC). The classifiers on the hybrid data were compared with ML models built on clinical data only. Results: The best ML classifier utilizing a hybrid set of clinical and model-driven data demonstrated ROC AUC of 0.82, an accuracy of 0.82, sensitivity of 0.85, and specificity of 0.78, improving quality over that of ML predictors built on clinical data from much larger datasets by more than 0.1. Distance from the LV pacing site to the post-infarction zone and ventricular activation characteristics under BiV pacing were shown as the most relevant model-driven features for CRT response classification. Conclusion: Our results suggest that combination of clinical and model-driven data increases the accuracy of classification models for CRT outcomes.
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Affiliation(s)
- Svyatoslav Khamzin
- Institute of Immunology and Physiology Ural Branch of the Russian Academy of Sciences, Yekaterinburg, Russia
| | - Arsenii Dokuchaev
- Institute of Immunology and Physiology Ural Branch of the Russian Academy of Sciences, Yekaterinburg, Russia
| | - Anastasia Bazhutina
- Institute of Immunology and Physiology Ural Branch of the Russian Academy of Sciences, Yekaterinburg, Russia.,Ural Federal University, Yekaterinburg, Russia
| | - Tatiana Chumarnaya
- Institute of Immunology and Physiology Ural Branch of the Russian Academy of Sciences, Yekaterinburg, Russia
| | - Stepan Zubarev
- Almazov National Medical Research Centre, Saint Petersburg, Russia
| | | | | | - Dmitry Lebedev
- Almazov National Medical Research Centre, Saint Petersburg, Russia
| | | | - Olga Solovyova
- Institute of Immunology and Physiology Ural Branch of the Russian Academy of Sciences, Yekaterinburg, Russia.,Ural Federal University, Yekaterinburg, Russia
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6
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Paton MF, Gierula J, Lowry JE, Cairns DA, Bose Rosling K, Cole CA, McGinlay M, Straw S, Byrom R, Cubbon RM, Kearney MT, Witte KK. Personalised reprogramming to prevent progressive pacemaker-related left ventricular dysfunction: A phase II randomised, controlled clinical trial. PLoS One 2021; 16:e0259450. [PMID: 34898655 PMCID: PMC8668131 DOI: 10.1371/journal.pone.0259450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Accepted: 10/15/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Pacemakers are widely utilised to treat bradycardia, but right ventricular (RV) pacing is associated with heightened risk of left ventricular (LV) systolic dysfunction and heart failure. We aimed to compare personalised pacemaker reprogramming to avoid RV pacing with usual care on echocardiographic and patient-orientated outcomes. METHODS A prospective phase II randomised, double-blind, parallel-group trial in 100 patients with a pacemaker implanted for indications other than third degree heart block for ≥2 years. Personalised pacemaker reprogramming was guided by a published protocol. Primary outcome was change in LV ejection fraction on echocardiography after 6 months. Secondary outcomes included LV remodeling, quality of life, and battery longevity. RESULTS Clinical and pacemaker variables were similar between groups. The mean age (SD) of participants was 76 (+/-9) years and 71% were male. Nine patients withdrew due to concurrent illness, leaving 91 patients in the intention-to-treat analysis. At 6 months, personalised programming compared to usual care, reduced RV pacing (-6.5±1.8% versus -0.21±1.7%; p<0.01), improved LV function (LV ejection fraction +3.09% [95% confidence interval (CI) 0.48 to 5.70%; p = 0.02]) and LV dimensions (LV end systolic volume indexed to body surface area -2.99mL/m2 [95% CI -5.69 to -0.29; p = 0.03]). Intervention also preserved battery longevity by approximately 5 months (+0.38 years [95% CI 0.14 to 0.62; p<0.01)) with no evidence of an effect on quality of life (+0.19, [95% CI -0.25 to 0.62; p = 0.402]). CONCLUSIONS Personalised programming in patients with pacemakers for bradycardia can improve LV function and size, extend battery longevity, and is safe and acceptable to patients. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT03627585.
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Affiliation(s)
- Maria F. Paton
- Leeds Institute of Cardiovascular and Metabolic Medicine, Multidisciplinary Cardiovascular Research Centre, University of Leeds, Leeds, United Kingdom
- Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - John Gierula
- Leeds Institute of Cardiovascular and Metabolic Medicine, Multidisciplinary Cardiovascular Research Centre, University of Leeds, Leeds, United Kingdom
| | - Judith E. Lowry
- Leeds Institute of Cardiovascular and Metabolic Medicine, Multidisciplinary Cardiovascular Research Centre, University of Leeds, Leeds, United Kingdom
| | - David A. Cairns
- Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, United Kingdom
| | - Kieran Bose Rosling
- Leeds Institute of Cardiovascular and Metabolic Medicine, Multidisciplinary Cardiovascular Research Centre, University of Leeds, Leeds, United Kingdom
| | | | | | - Sam Straw
- Leeds Institute of Cardiovascular and Metabolic Medicine, Multidisciplinary Cardiovascular Research Centre, University of Leeds, Leeds, United Kingdom
| | - Rowena Byrom
- Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Richard M. Cubbon
- Leeds Institute of Cardiovascular and Metabolic Medicine, Multidisciplinary Cardiovascular Research Centre, University of Leeds, Leeds, United Kingdom
| | - Mark T. Kearney
- Leeds Institute of Cardiovascular and Metabolic Medicine, Multidisciplinary Cardiovascular Research Centre, University of Leeds, Leeds, United Kingdom
| | - Klaus K. Witte
- Leeds Institute of Cardiovascular and Metabolic Medicine, Multidisciplinary Cardiovascular Research Centre, University of Leeds, Leeds, United Kingdom
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7
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Loring Z, Friedman DJ, Emerek K, Graff C, Sørensen PL, Hansen SM, Wieslander B, Ugander M, Søgaard P, Atwater BD. Lead one ratio in left bundle branch block predicts poor cardiac resynchronization therapy response. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2020; 43:503-510. [PMID: 32285950 DOI: 10.1111/pace.13916] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Revised: 02/27/2020] [Accepted: 03/29/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND A low electrocardiogram (ECG) lead one ratio (LOR) of the maximum positive/negative QRS amplitudes is associated with lower left ventricular ejection fraction (LVEF) and worse outcomes in left bundle branch block (LBBB); however, the impact of LOR on cardiac resynchronization therapy (CRT) outcomes is unknown. We compared clinical outcomes and echocardiographic changes after CRT implantation by LOR. METHODS Consecutive CRT-defibrillator recipients with LBBB implanted between 2006 and 2015 at Duke University Medical Center were included (N = 496). Time to heart transplant, left ventricular assist device (LVAD) implantation, or death was compared among patients with LOR <12 vs ≥12 using Cox-proportional hazard models. Changes in LVEF and LV volumes after CRT were compared by LOR. RESULTS Baseline ECG LOR <12 was associated with an adjusted hazard ratio (HR) of 1.69 (95% CI: 1.12-2.40, P = .01) for heart transplant, LVAD, or death. Patients with LOR <12 had less reduction of LV end diastolic volume (ΔLVEDV -4 ± 21 vs -13 ± 23%, P = .04) and LV end systolic volume (ΔLVESV -9 ± 27 vs -22 ± 26%, P = .03) after CRT. In patients with QRS duration (QRSd) ≥150 ms, LOR <12 was associated with an adjusted HR of 2.01 (95% CI 1.21-3.35, P = .008) for heart transplant, LVAD, or death, compared with LOR ≥12. CONCLUSIONS Baseline ECG LOR <12 portends worse outcomes after CRT implantation in patients with LBBB, specifically among those with QRSd ≥150 ms. This ECG ratio may identify patients with a class I indication for CRT implantation at high risk for poor postimplantation outcomes.
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Affiliation(s)
- Zak Loring
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina.,Duke Clinical Research Institute, Durham, North Carolina
| | - Daniel J Friedman
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina.,Duke Clinical Research Institute, Durham, North Carolina
| | - Kasper Emerek
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Claus Graff
- Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
| | - Peter L Sørensen
- Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
| | - Steen M Hansen
- Unit of Epidemiology and Biostatistics, Aalborg University Hospital, Aalborg, Denmark
| | - Bjorn Wieslander
- Department of Clinical Physiology, Karolinska Institute, and Karolinska University Hospital, Stockholm, Sweden
| | - Martin Ugander
- Department of Clinical Physiology, Karolinska Institute, and Karolinska University Hospital, Stockholm, Sweden
| | - Peter Søgaard
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Brett D Atwater
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina
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AlTurki A, Lima PY, Bernier ML, Garcia D, Vidal A, Toscani B, Diaz S, Montemezzo M, Al-Dossari A, Hadjis T, Joza J, Essebag V. Optimization of Chronic Cardiac Resynchronization Therapy Using Fusion Pacing Algorithm Improves Echocardiographic Response. CJC Open 2020; 2:62-70. [PMID: 32190827 PMCID: PMC7067690 DOI: 10.1016/j.cjco.2019.12.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Accepted: 12/22/2019] [Indexed: 11/15/2022] Open
Abstract
Background Whether reprogramming of cardiac resynchronization therapy (CRT) to increase electrical synchrony translates into echocardiographic improvement remains unclear. SyncAV is an algorithm that allows fusion of intrinsic conduction with biventricular pacing. We aimed to assess whether reprogramming chronically implanted CRT devices with SyncAV is associated with improved echocardiographic parameters. Methods Patients at a quaternary center with previously implanted CRT devices with a programmable SyncAV algorithm underwent routine electrocardiography-based SyncAV optimization during regular device clinic visits. This analysis included only patients who could be programmed to the SyncAV algorithm (i.e., in sinus rhythm with intrinsic atrioventricular conduction). Echocardiography was performed before and 6 months after CRT optimization. Results Of 64 consecutive, potentially eligible patients who underwent assessment, 34 who were able to undergo SyncAV programming were included. Their mean age was 74 ± 9 years, 41% were female, and 59% had ischemic cardiomyopathy. The mean time from CRT implant to SyncAV optimization was 17.8 ± 8.5 months. At 6-month follow-up, SyncAV optimization was associated with a significant increase in left ventricular ejection fraction (LVEF) (mean LVEF 36.5% ± 13.3% vs 30.9% ± 13.3%; P < 0.001) and a reduction in left ventricular end-systolic volume (LVESV) (mean LVESV 110.5 ± 57.5 mL vs 89.6 ± 52.4 mL; P < 0.001) compared with baseline existing CRT programming. Conclusion CRT reprogramming to maximize biventricular fusion pacing significantly increased LVEF and reduced LVESV in patients with chronic CRT devices. Further studies are needed to assess if a continuous fusion pacing algorithm improves long-term clinical outcomes and to identify which patients are most likely to derive benefit.
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Affiliation(s)
- Ahmed AlTurki
- Division of Cardiology, McGill University Health Center, Montreal, Quebec, Canada
| | - Pedro Y Lima
- Division of Cardiology, McGill University Health Center, Montreal, Quebec, Canada
| | - Martin L Bernier
- Division of Cardiology, McGill University Health Center, Montreal, Quebec, Canada
| | - Daniel Garcia
- Division of Cardiology, McGill University Health Center, Montreal, Quebec, Canada
| | - Alejandro Vidal
- Division of Cardiology, McGill University Health Center, Montreal, Quebec, Canada
| | - Bruno Toscani
- Division of Cardiology, McGill University Health Center, Montreal, Quebec, Canada
| | - Sergio Diaz
- Division of Cardiology, McGill University Health Center, Montreal, Quebec, Canada
| | - Mauricio Montemezzo
- Division of Cardiology, McGill University Health Center, Montreal, Quebec, Canada
| | - Alaa Al-Dossari
- Division of Cardiology, McGill University Health Center, Montreal, Quebec, Canada
| | - Tomy Hadjis
- Division of Cardiology, McGill University Health Center, Montreal, Quebec, Canada
| | - Jacqueline Joza
- Division of Cardiology, McGill University Health Center, Montreal, Quebec, Canada
| | - Vidal Essebag
- Division of Cardiology, McGill University Health Center, Montreal, Quebec, Canada
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9
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Kuznetsov VA, Soldatova AM, Enina TN, Krinochkin DV, Dyachkov SM. [Does the lack of left ventricular reverse remodeling always mean non - response to cardiac resynchronization therapy?]. TERAPEVT ARKH 2019; 91:10-15. [PMID: 32598583 DOI: 10.26442/00403660.2019.12.000102] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Indexed: 11/22/2022]
Abstract
AIM To evaluate clinical, morphological, functional features and mortality level in patients with different value of left ventricular reverse remodeling after cardiac resynchronization therapy (CRT). MATERIALS AND METHODS The study enrolled 112 patients (mean age 54.6±9.9 years, 83.5% men) with left ventricular ejection fraction (LVEF) І35%, NYHA functional class II-IV. We enrolled patients with QRS width >120 ms or QRS.
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Affiliation(s)
- V A Kuznetsov
- Tyumen Cardiology Research Center - Branch of Tomsk National Research Medical Center, Russian Academy of Science
| | - A M Soldatova
- Tyumen Cardiology Research Center - Branch of Tomsk National Research Medical Center, Russian Academy of Science
| | - T N Enina
- Tyumen Cardiology Research Center - Branch of Tomsk National Research Medical Center, Russian Academy of Science
| | - D V Krinochkin
- Tyumen Cardiology Research Center - Branch of Tomsk National Research Medical Center, Russian Academy of Science
| | - S M Dyachkov
- Tyumen Cardiology Research Center - Branch of Tomsk National Research Medical Center, Russian Academy of Science
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10
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Singh JP, Abraham WT, Auricchio A, Delnoy PP, Gold M, Reddy VY, Sanders P, Lindenfeld J, Rinaldi CA. Design and rationale for the Stimulation Of the Left Ventricular Endocardium for Cardiac Resynchronization Therapy in non-responders and previously untreatable patients (SOLVE-CRT) trial. Am Heart J 2019; 217:13-22. [PMID: 31472360 DOI: 10.1016/j.ahj.2019.04.002] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Accepted: 04/02/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND Cardiac resynchronization therapy (CRT) improves outcomes, functional capacity and quality of life in patients with heart failure. Despite two decades of experience with CRT, the rate of non-response remains approximately 30%. CRT efficacy is impacted by pacing location, which is anatomically limited in conventional systems. A new wireless endocardial left ventricular (LV) pacing system allows CRT without such limitations and has shown promise in open-label studies. The purpose of this study is to evaluate its use in a patient population with poor therapeutic alternatives. METHODS The SOLVE CRT study is an international, multi-center, randomized, double-blind, sham-controlled trial of patients with Class I and IIa indications for CRT who have either failed to respond to or have been unable to receive conventional CRT. Enrollment will comprise 350 patients implanted with the wireless CRT system randomized 1:1 to therapy on (Treatment) or therapy off (Control) for the six-month period over which trial primary endpoints will be evaluated. The primary safety endpoint will measure the proportion of patients free from system- and procedure-related complications. Primary efficacy endpoints will assess absolute change in LV end-systolic volume LVESV, proportion of patients reducing LVESV by ≥15% and clinical composite score for Treatment versus Control patients. Primary endpoints will be evaluated on an intention-to-treat basis, though per-protocol and as-treated analysis will also be performed. CONCLUSION SOLVE-CRT will quantify the safety and effectiveness of wireless CRT in non-responders to conventional CRT and indicated patients who have been unable to receive CRT via the usual transvenous approach.
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11
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Khurwolah MR, Yao J, Kong XQ. Adverse Consequences of Right Ventricular Apical Pacing and Novel Strategies to Optimize Left Ventricular Systolic and Diastolic Function. Curr Cardiol Rev 2019; 15:145-155. [PMID: 30499419 PMCID: PMC6520581 DOI: 10.2174/1573403x15666181129161839] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Revised: 11/20/2018] [Accepted: 11/22/2018] [Indexed: 11/25/2022] Open
Abstract
Several studies have focused on the deleterious consequences of Right Ventricular Apical (RVA) pacing on Left Ventricular (LV) function, mediated by pacing-induced ventricular dyssyn-chrony. Therapeutic strategies to reduce the detrimental consequences of RVA pacing have been pro-posed, that includes upgrading of RVA pacing to Cardiac Resynchronization Therapy (CRT), alterna-tive Right Ventricular (RV) pacing sites, minimal ventricular pacing strategies, as well as atrial-based pacing. In developing countries, single chamber RV pacing still constitutes a majority of cases of permanent pacing, and assessment of the optimal RV pacing site is of paramount importance. In chronically-paced patients, it is crucial to maintain as close and normal LV physiological function as possible, by minimizing ventricular dyssynchrony, reducing the chances for heart failure and other complications to develop. This review provides an analysis of the deleterious immediate and long-term consequences of RVA pacing, and the most recent available evidence regarding improvements in pacing options and strategies to optimize LV diastolic and systolic function. Furthermore, the place of advanced echocardiography in the identification of patients with pacing-induced LV dysfunction, the potential role of a new predictor of LV dysfunction in RV-paced subjects, and the long- term out-comes of patients with RV septal pacing will be explored
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Affiliation(s)
- Mohammad Reeaze Khurwolah
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, Jiangsu Province, China
| | - Jing Yao
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, Jiangsu Province, China
| | - Xiang-Qing Kong
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, Jiangsu Province, China
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12
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Martins S, Carvalheiro T, Laranjeira P, Martinho A, Elvas L, Gonçalves L, Tomaz C, António N, Paiva A. Impact of cardiac resynchronization therapy on circulating IL-17 producing cells in patients with advanced heart failure. J Interv Card Electrophysiol 2018; 54:257-265. [PMID: 30483979 DOI: 10.1007/s10840-018-0491-3] [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: 06/28/2018] [Accepted: 11/14/2018] [Indexed: 11/28/2022]
Abstract
PURPOSE IL-17-producing T cells have been implicated in the inflammatory milieu of chronic heart failure (CHF), which implies a dismal prognosis in affected patients. The aim of this study was to evaluate the impact of cardiac resynchronization therapy (CRT) on the frequency and functional activity of Th17 and Tc17 cells, as well as, on IL-17 mRNA expression in patients with CHF. METHODS Twenty-eight patients with CHF, analyzed before CRT (T0) and 6 months later (T6), and 15 healthy controls (HC) were enrolled in this study. Circulating Th17 and Tc17 cells were evaluated by flow cytometry. The quantification of IL-17A mRNA expression was performed by real-time PCR. RESULTS Circulating Tc17 cells tended to be higher in CHF patients submitted to CRT than in HC (0.92% (0.24-3.32) versus 0.60% (0.09-3.68), although not reaching statistical significance. The frequency of Tc17 cells in CHF patients significantly decreases after CRT reaching levels similar to those of HC (0.92% (0.24-3.32) at T0 versus 0.56% (0.21-4.20) at T6, P < 0.05), mainly due to responders to CRT. Additionally, the expression of IL-17 mRNA was detected in a few number of responder patients at T0 (27%) and only detected in one responder at T6 (7%). Conversely, in non-responders, the proportion of patients exhibiting IL-17 mRNA expression increases from baseline (17%) to T6 (42%). No significant differences were observed in Th17 cells between HC, CHF patients in T0 and patients in T6. CONCLUSION The inflammatory response mediated by circulating IL-17 producing cells seems to be suppressed by CRT, particularly in responders.
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Affiliation(s)
- Sílvia Martins
- CICS-UBI - Centro de Investigação em Ciências da Saúde, Universidade da Beira Interior, Covilhã, Portugal.,Coimbra Institute for Clinical and Biomedical Research, Faculdade de Medicina, Coimbra, Portugal
| | - Tiago Carvalheiro
- Centro do Sangue e da Transplantação de Coimbra, Instituto Português do Sangue e da Transplantação, Coimbra, Portugal
| | - Paula Laranjeira
- Coimbra Institute for Clinical and Biomedical Research, Faculdade de Medicina, Coimbra, Portugal.,Flow Cytometry Unit, Department of Clinical Pathology, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - António Martinho
- Centro do Sangue e da Transplantação de Coimbra, Instituto Português do Sangue e da Transplantação, Coimbra, Portugal
| | - Luís Elvas
- Cardiology Department, Coimbra Hospital and Universitary Centre, Coimbra, Portugal.,Faculty of Medicine, Coimbra University, Coimbra, Portugal
| | - Lino Gonçalves
- Cardiology Department, Coimbra Hospital and Universitary Centre, Coimbra, Portugal.,Faculty of Medicine, Coimbra University, Coimbra, Portugal
| | - Cândida Tomaz
- CICS-UBI - Centro de Investigação em Ciências da Saúde, Universidade da Beira Interior, Covilhã, Portugal.,Departamento de Química, Universidade da Beira Interior, Covilhã, Portugal
| | - Natália António
- Cardiology Department, Coimbra Hospital and Universitary Centre, Coimbra, Portugal.,Faculty of Medicine, Coimbra University, Coimbra, Portugal
| | - Artur Paiva
- Coimbra Institute for Clinical and Biomedical Research, Faculdade de Medicina, Coimbra, Portugal. .,Flow Cytometry Unit, Department of Clinical Pathology, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal. .,Instituto Politécnico de Coimbra, ESTESC - Coimbra Health School, Ciências Biomédicas Laboratoriais, Coimbra, Portugal. .,Unidade de Gestão Operacional de Citometria, Serviço de Patologia Clínica, Centro Hospitalar e Universitário de Coimbra, Ed. S. Jerónimo, Praceta Mota Pinto, 3001-301, Coimbra, Portugal.
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13
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Sieniewicz BJ, Gould J, Porter B, Sidhu BS, Behar JM, Claridge S, Niederer S, Rinaldi CA. Optimal site selection and image fusion guidance technology to facilitate cardiac resynchronization therapy. Expert Rev Med Devices 2018; 15:555-570. [PMID: 30019954 PMCID: PMC6178093 DOI: 10.1080/17434440.2018.1502084] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Accepted: 07/12/2018] [Indexed: 12/30/2022]
Abstract
INTRODUCTION Cardiac resynchronization therapy (CRT) has emerged as one of the few effective treatments for heart failure. However, up to 50% of patients derive no benefit. Suboptimal left ventricle (LV) lead position is a potential cause of poor outcomes while targeted lead deployment has been associated with enhanced response rates. Image-fusion guidance systems represent a novel approach to CRT delivery, allowing physicians to both accurately track and target a specific location during LV lead deployment. AREAS COVERED This review will provide a comprehensive evaluation of how to define the optimal pacing site. We will evaluate the evidence for delivering targeted LV stimulation at sites displaying favorable viability or advantageous mechanical or electrical properties. Finally, we will evaluate several emerging image-fusion guidance systems which aim to facilitate optimal site selection during CRT. EXPERT COMMENTARY Targeted LV lead deployment is associated with reductions in morbidity and mortality. Assessment of tissue characterization and electrical latency are critical and can be achieved in a number of ways. Ultimately, the constraints of coronary sinus anatomy have forced the exploration of novel means of delivering CRT including endocardial pacing which hold promise for the future of CRT delivery.
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Affiliation(s)
- Benjamin J. Sieniewicz
- Division of Imaging Sciences and Biomedical Engineering, King’s College London, London, United Kingdom
- Cardiology Department, Guys and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Justin Gould
- Division of Imaging Sciences and Biomedical Engineering, King’s College London, London, United Kingdom
- Cardiology Department, Guys and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Bradley Porter
- Division of Imaging Sciences and Biomedical Engineering, King’s College London, London, United Kingdom
- Cardiology Department, Guys and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Baldeep S Sidhu
- Division of Imaging Sciences and Biomedical Engineering, King’s College London, London, United Kingdom
- Cardiology Department, Guys and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Jonathan M Behar
- Division of Imaging Sciences and Biomedical Engineering, King’s College London, London, United Kingdom
- Cardiology Department, Guys and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Simon Claridge
- Division of Imaging Sciences and Biomedical Engineering, King’s College London, London, United Kingdom
- Cardiology Department, Guys and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Steve Niederer
- Division of Imaging Sciences and Biomedical Engineering, King’s College London, London, United Kingdom
| | - Christopher A. Rinaldi
- Division of Imaging Sciences and Biomedical Engineering, King’s College London, London, United Kingdom
- Cardiology Department, Guys and St Thomas’ NHS Foundation Trust, London, United Kingdom
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14
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Safety and Effectiveness of Medical Device Therapy. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2018; 1065:107-121. [DOI: 10.1007/978-3-319-77932-4_7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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15
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Vrtovec B, Poglajen G, Sever M, Zemljic G, Frljak S, Cerar A, Cukjati M, Jaklic M, Cernelc P, Haddad F, Wu JC. Effects of Repetitive Transendocardial CD34
+
Cell Transplantation in Patients With Nonischemic Dilated Cardiomyopathy. Circ Res 2018; 123:389-396. [DOI: 10.1161/circresaha.117.312170] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Bojan Vrtovec
- From the Advanced Heart Failure and Transplantation Center (B.V., G.P., G.Z., S.F., A.C., M.J.)
| | - Gregor Poglajen
- From the Advanced Heart Failure and Transplantation Center (B.V., G.P., G.Z., S.F., A.C., M.J.)
| | | | - Gregor Zemljic
- From the Advanced Heart Failure and Transplantation Center (B.V., G.P., G.Z., S.F., A.C., M.J.)
| | - Sabina Frljak
- From the Advanced Heart Failure and Transplantation Center (B.V., G.P., G.Z., S.F., A.C., M.J.)
| | - Andraz Cerar
- From the Advanced Heart Failure and Transplantation Center (B.V., G.P., G.Z., S.F., A.C., M.J.)
| | - Marko Cukjati
- UMC Ljubljana, Slovenia; National Blood Transfusion Institute, Ljubljana, Slovenia (M.C.)
| | - Martina Jaklic
- From the Advanced Heart Failure and Transplantation Center (B.V., G.P., G.Z., S.F., A.C., M.J.)
| | | | - François Haddad
- Stanford Cardiovascular Institute, Stanford University School of Medicine, CA (F.H., J.C.W.)
| | - Joseph C. Wu
- Stanford Cardiovascular Institute, Stanford University School of Medicine, CA (F.H., J.C.W.)
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16
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Mele D, Bertini M, Malagù M, Nardozza M, Ferrari R. Current role of echocardiography in cardiac resynchronization therapy. Heart Fail Rev 2018; 22:699-722. [PMID: 28714039 DOI: 10.1007/s10741-017-9636-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Cardiac resynchronization therapy (CRT) is an established treatment for patients with heart failure and left ventricular systolic dysfunction. Patients are usually assessed by echocardiography, which provides a number of anatomical and functional information used for cardiac dyssynchrony assessment, prognostic stratification, identification of the optimal site of pacing in the left ventricle, optimization of the CRT device, and patient follow-up. Compared to other cardiac imaging techniques, echocardiography has the advantage to be non-invasive, repeatable, and safe, without exposure to ionizing radiation or nefrotoxic contrast. In this article, we review current evidence about the role of echocardiography before, during, and after the implantation of a CRT device.
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Affiliation(s)
- Donato Mele
- Centro Cardiologico Universitario and LTTA Centre, University of Ferrara, Ferrara, Italy. .,Noninvasive Cardiology Unit, Azienda Ospedaliero-Universitaria, Via Aldo Moro 8, 44124, Ferrara, Cona, Italy.
| | - Matteo Bertini
- Centro Cardiologico Universitario and LTTA Centre, University of Ferrara, Ferrara, Italy
| | - Michele Malagù
- Centro Cardiologico Universitario and LTTA Centre, University of Ferrara, Ferrara, Italy
| | - Marianna Nardozza
- Centro Cardiologico Universitario and LTTA Centre, University of Ferrara, Ferrara, Italy
| | - Roberto Ferrari
- Centro Cardiologico Universitario and LTTA Centre, University of Ferrara, Ferrara, Italy.,Maria Cecilia Hospital, GVM Care & Research, E.S. Health Science Foundation, Cotignola, RA, Italy
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17
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Impact of cardiac resynchronization therapy on inflammatory biomarkers and cardiac remodeling: The paradox of functional and echocardiographic response. Rev Port Cardiol 2018; 37:105-113. [PMID: 29503051 DOI: 10.1016/j.repc.2017.06.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2017] [Revised: 03/26/2017] [Accepted: 06/29/2017] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Response to cardiac resynchronization therapy (CRT) can currently be assessed by clinical or echocardiographic criteria, and there is no strong evidence supporting the use of one rather than the other. Reductions in B-type natriuretic peptide (BNP) and C-reactive protein (CRP) have been shown to be associated with CRT response. This study aims to assess variation in BNP and CRP six months after CRT and to correlate this variation with criteria of functional and echocardiographic response. METHODS Patients undergoing CRT were prospectively enrolled between 2011 and 2014. CRT response was defined by echocardiography (15% reduction in left ventricular end-systolic volume) and by cardiopulmonary exercise testing (10% increase in peak oxygen consumption) from baseline to six months after device implantation. RESULTS A total of 115 patients were enrolled (68.7% male, mean age 68.6±10.5 years). Echocardiographic response was seen in 51.4% and 59.2% were functional responders. There was no statistical correlation between the two. Functional response was associated with a significantly greater reduction in BNP (-167.6±264.1 vs. -24.9±269.4 pg/ml; p=0.044) and CRP levels (-1.6±4.4 vs. 2.4±9.9 mg/l; p=0.04). Nonetheless, a non-significant reduction in BNP and CRP was observed in echocardiographic responders (BNP -144.7±260.2 vs. -66.1±538.2 pg/ml and CRP -7.1±24.3 vs. 0.8±10.3 mg/l; p>0.05). CONCLUSION An increase in exercise capacity after CRT implantation is associated with improvement in myocardial remodeling and inflammatory biomarkers. This finding highlights the importance of improvement in functional capacity after CRT implantation, not commonly considered a criterion of CRT response.
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18
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Almeida-Morais L, Abreu A, Oliveira M, Silva Cunha P, Rodrigues I, Portugal G, Rio P, Soares R, Mota Carmo M, Cruz Ferreira R. Impact of cardiac resynchronization therapy on inflammatory biomarkers and cardiac remodeling: The paradox of functional and echocardiographic response. REVISTA PORTUGUESA DE CARDIOLOGIA (ENGLISH EDITION) 2018. [DOI: 10.1016/j.repce.2018.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
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19
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Ricci F, Mele D, Bianco F, Bucciarelli V, De Caterina R, Gallina S. Right heart-pulmonary circulation unit and cardiac resynchronization therapy. Am Heart J 2017; 185:1-16. [PMID: 28267462 DOI: 10.1016/j.ahj.2016.11.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Accepted: 11/07/2016] [Indexed: 11/15/2022]
Abstract
Clinical response to cardiac resynchronization therapy (CRT) has been known for years to be highly variable, with a spectrum of responses from no change or even deterioration of cardiac function to spectacular improvements. In the plethora of clinical, echocardiographic, biohumoral, and electrophysiological predictors of response to CRT and postimplant issues besides patient selection, the role of right ventricular (RV) function has been largely overlooked. In reviewing current evidence, we noticed conflicting results between observational studies and randomized trials not only concerning the impact of baseline RV function on CRT efficacy but also on the effects of CRT on RV size and function. Hence, we aimed to provide a critical reappraisal of current knowledge and unresolved issues on the reciprocal interactions between RV function and CRT, shifting the spotlight on the concept of right heart pulmonary circulation unit and on the clinical and prognostic significance of impaired ventricular-arterial coupling reserve. In this viewpoint, we propose that (1) CRT should not be denied to potential candidate because of "isolated" RV dysfunction and (2) assessment of baseline right heart pulmonary circulation unit and its dynamic response to pharmacological stress should be considered in future studies, as well as in the preimplant evaluation of individual candidates among other clinical factors.
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Affiliation(s)
- Fabrizio Ricci
- Institute of Cardiology, "G.d'Annunzio" University, Chieti, Italy; Department of Neuroscience and Imaging and ITAB-Institute for Advanced Biomedical Technologies, University "G. d'Annunzio", Chieti, Italy.
| | - Donato Mele
- Noninvasive Cardiac Unit, University Hospital of Ferrara, Ferrara, Italy
| | - Francesco Bianco
- Institute of Cardiology, "G.d'Annunzio" University, Chieti, Italy
| | | | | | - Sabina Gallina
- Institute of Cardiology, "G.d'Annunzio" University, Chieti, Italy
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20
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Electroanatomic Properties of the Myocardium Predict Response to CD34+ Cell Therapy in Patients With Ischemic and Nonischemic Heart Failure. J Card Fail 2017; 23:153-160. [DOI: 10.1016/j.cardfail.2016.08.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Revised: 07/24/2016] [Accepted: 08/09/2016] [Indexed: 12/27/2022]
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21
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Auger DA, Bilchick KC, Gonzalez JA, Cui SX, Holmes JW, Kramer CM, Salerno M, Epstein FH. Imaging left-ventricular mechanical activation in heart failure patients using cine DENSE MRI: Validation and implications for cardiac resynchronization therapy. J Magn Reson Imaging 2017; 46:887-896. [PMID: 28067978 DOI: 10.1002/jmri.25613] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2016] [Revised: 12/09/2016] [Accepted: 12/10/2016] [Indexed: 11/06/2022] Open
Abstract
PURPOSE To image late mechanical activation and identify effective left-ventricular (LV) pacing sites for cardiac resynchronization therapy (CRT). There is variability in defining mechanical activation time, with some studies using the time to peak strain (TPS) and some using the time to the onset of circumferential shortening (TOS). We developed improved methods for imaging mechanical activation and evaluated them in heart failure (HF) patients undergoing CRT. MATERIALS AND METHODS We applied active contours to cine displacement encoding with stimulated echoes (DENSE) strain images to detect TOS. Six healthy volunteers underwent magnetic resonance imaging (MRI) at 1.5T, and 50 patients underwent pre-CRT MRI (strain, scar, volumes) and echocardiography, assessment of the electrical activation time (Q-LV) at the LV pacing site, and echocardiography assessment of LV reverse remodeling 6 months after CRT. TPS at the LV pacing site was also measured by DENSE. RESULTS The latest TOS was greater in HF patients vs. healthy subjects (112 ± 28 msec vs. 61 ± 7 msec, P < 0.01). The correlation between TOS and Q-LV was strong (r > 0.75; P < 0.001) and better than between TPS and Q-LV (r < 0.62; P ≥ 0.006). Twenty-three of 50 patients had the latest activating segment in a region other than the mid-ventricular lateral wall, the most common site for the CRT LV lead. Using a multivariable model, TOS/QRS was significantly associated with LV reverse remodeling even after adjustment for overall dyssynchrony and scar (P < 0.05), whereas TPS was not (P = 0.49). CONCLUSION Late activation by cine DENSE TOS analysis is associated with improved LV reverse remodeling with CRT and deserves further study as a tool to achieve optimal LV lead placement in CRT. LEVEL OF EVIDENCE 1 Technical Efficacy: Stage 1 J. MAGN. RESON. IMAGING 2017;46:887-896.
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Affiliation(s)
- Daniel A Auger
- Department of Biomedical Engineering, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Kenneth C Bilchick
- Medicine/Cardiology/Electrophysiology, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Jorge A Gonzalez
- Medicine/Cardiology/Electrophysiology, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Sophia X Cui
- Department of Biomedical Engineering, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Jeffrey W Holmes
- Department of Biomedical Engineering, University of Virginia Health System, Charlottesville, Virginia, USA.,Medicine/Cardiology/Electrophysiology, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Christopher M Kramer
- Medicine/Cardiology/Electrophysiology, University of Virginia Health System, Charlottesville, Virginia, USA.,Radiology/Medical Imaging, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Michael Salerno
- Department of Biomedical Engineering, University of Virginia Health System, Charlottesville, Virginia, USA.,Medicine/Cardiology/Electrophysiology, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Frederick H Epstein
- Department of Biomedical Engineering, University of Virginia Health System, Charlottesville, Virginia, USA.,Radiology/Medical Imaging, University of Virginia Health System, Charlottesville, Virginia, USA
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22
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Tomini F, Prinzen F, van Asselt ADI. A review of economic evaluation models for cardiac resynchronization therapy with implantable cardioverter defibrillators in patients with heart failure. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2016; 17:1159-1172. [PMID: 26728985 PMCID: PMC5080299 DOI: 10.1007/s10198-015-0752-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/02/2015] [Accepted: 11/25/2015] [Indexed: 06/05/2023]
Abstract
OBJECTIVES Cardiac resynchronization therapy with a biventricular pacemaker (CRT-P) is an effective treatment for dyssynchronous heart failure (DHF). Adding an implantable cardioverter defibrillator (CRT-D) may further reduce the risk of sudden cardiac death (SCD). However, if the majority of patients do not require shock therapy, the cost-effectiveness ratio of CRT-D compared to CRT-P may be high. The objective of this study was to systematically review decision models evaluating the cost-effectiveness of CRT-D for patients with DHF, compare the structure and inputs of these models and identify the main factors influencing the ICERs for CRT-D. METHODS A comprehensive search strategy of Medline (Ovid), Embase (Ovid) and EconLit identified eight cost-effectiveness models evaluating CRT-D against optimal pharmacological therapy (OPT) and/or CRT-P. RESULTS The selected economic studies differed in terms of model structure, treatment path, time horizons, and sources of efficacy data. CRT-D was found cost-effective when compared to OPT but its cost-effectiveness became questionable when compared to CRT-P. CONCLUSIONS Cost-effectiveness of CRT-D may increase depending on improvement of all-cause mortality rates and HF mortality rates in patients who receive CRT-D, costs of the device, and battery life. In particular, future studies need to investigate longer-term mortality rates and identify CRT-P patients that will gain the most, in terms of life expectancy, from being treated with a CRT-D.
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Affiliation(s)
- F Tomini
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Centre, Maastricht, The Netherlands.
- Department of Physiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands.
| | - F Prinzen
- Department of Physiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
| | - A D I van Asselt
- Department of Pharmacy, University of Groningen, Groningen, The Netherlands
- Department of Epidemiology, University Medical Centre Groningen, Groningen, The Netherlands
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23
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Behar JM, Claridge S, Jackson T, Sieniewicz B, Porter B, Webb J, Rajani R, Kapetanakis S, Carr-White G, Rinaldi CA. The role of multi modality imaging in selecting patients and guiding lead placement for the delivery of cardiac resynchronization therapy. Expert Rev Cardiovasc Ther 2016; 15:93-107. [DOI: 10.1080/14779072.2016.1252674] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Jonathan M Behar
- Department of Imaging Sciences & Biomedical Engineering, King’s College London, London, UK
- Department of Cardiology, St. Thomas’ Hospital, London, UK
| | - Simon Claridge
- Department of Imaging Sciences & Biomedical Engineering, King’s College London, London, UK
- Department of Cardiology, St. Thomas’ Hospital, London, UK
| | - Tom Jackson
- Department of Imaging Sciences & Biomedical Engineering, King’s College London, London, UK
- Department of Cardiology, St. Thomas’ Hospital, London, UK
| | - Ben Sieniewicz
- Department of Imaging Sciences & Biomedical Engineering, King’s College London, London, UK
- Department of Cardiology, St. Thomas’ Hospital, London, UK
| | - Bradley Porter
- Department of Imaging Sciences & Biomedical Engineering, King’s College London, London, UK
- Department of Cardiology, St. Thomas’ Hospital, London, UK
| | - Jessica Webb
- Department of Imaging Sciences & Biomedical Engineering, King’s College London, London, UK
- Department of Cardiology, St. Thomas’ Hospital, London, UK
| | - Ronak Rajani
- Department of Cardiology, St. Thomas’ Hospital, London, UK
| | | | | | - Christopher A Rinaldi
- Department of Imaging Sciences & Biomedical Engineering, King’s College London, London, UK
- Department of Cardiology, St. Thomas’ Hospital, London, UK
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24
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Karaca O, Gunes HM, Omaygenc MO, Cakal B, Cakal SD, Demir GG, Kizilirmak F, Gokdeniz T, Barutcu I, Boztosun B, Kilicaslan F. Predicting Ventricular Arrhythmias in Cardiac Resynchronization Therapy: The Impact of Persistent Electrical Dyssynchrony. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2016; 39:969-77. [PMID: 27333978 DOI: 10.1111/pace.12908] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/29/2015] [Revised: 05/03/2016] [Accepted: 06/09/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND Although response to cardiac resynchronization therapy (CRT) has been conventionally assessed with left ventricular volume reduction, ventricular arrhythmias (ventricular tachycardia/ventricular fibrillation [VT/VF]) are of critical importance associated with unfavorable outcomes even in the "superresponders" to therapy. We evaluated the predictors of VT/VF and the association of residual dyssynchrony during follow-up. METHODS Ninety-five patients receiving CRT were followed-up for 9 ± 3 months. Post-CRT dyssynchrony was defined as a prolonged QRS duration (QRSd) for persistent electrical dyssynchrony (ED), and a Yu index ≥ 33 ms for persistent mechanical dyssynchrony. The first VT/VF episode, including nonsustained VT detected on device interrogation and/or appropriate antitachycardia pacing or shock for VT/VF, were the end points of the study. RESULTS Forty-five patients who reached the study end points had significantly lower mean ΔQRS (baseline QRSd - post-CRT QRSd) values than those without VT/VF (-20.8 ± 28.9 ms vs -6.6 ± 30.7 ms, P = 0.022). Both the baseline and post-CRT QRSds, along with the Yu index values, were not different in two groups. Patients with VT/VF were statistically more likely to have persistent ED (38% vs 9%, P = 0.021). Kaplan-Meier curves showed that a negative ΔQRS was associated with a higher incidence of VT/VF during follow-up (P = 0.016). A multivariate Cox model revealed that QRS prolongation was an independent predictor of VT/VF after CRT (P = 0.029). CONCLUSIONS A negative ΔQRS, also called persistent ED, is associated with VT/VF. Narrowest possible QRSd might be a reliable goal of both implantation and optimization of devices to reduce arrhythmic events after CRT.
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Affiliation(s)
- Oguz Karaca
- Cardiology Department, Medipol University Faculty of Medicine, Istanbul, Turkey.
| | - Haci M Gunes
- Cardiology Department, Medipol University Faculty of Medicine, Istanbul, Turkey
| | | | - Beytullah Cakal
- Cardiology Department, Medipol University Faculty of Medicine, Istanbul, Turkey
| | - Sinem Deniz Cakal
- Cardiology Department, Medipol University Faculty of Medicine, Istanbul, Turkey
| | | | - Filiz Kizilirmak
- Cardiology Department, Medipol University Faculty of Medicine, Istanbul, Turkey
| | - Tayyar Gokdeniz
- Cardiology Department, Medipol University Faculty of Medicine, Istanbul, Turkey
| | - Irfan Barutcu
- Cardiology Department, Medipol University Faculty of Medicine, Istanbul, Turkey
| | - Bilal Boztosun
- Cardiology Department, Medipol University Faculty of Medicine, Istanbul, Turkey
| | - Fethi Kilicaslan
- Cardiac Electrophysiology, Medipol University Faculty of Medicine, Istanbul, Turkey
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Menet A, Guyomar Y, Ennezat PV, Graux P, Castel AL, Delelis F, Heuls S, Cuvelier E, Gevaert C, Le Goffic C, Tribouilloy C, Maréchaux S. Prognostic value of left ventricular reverse remodeling and performance improvement after cardiac resynchronization therapy: A prospective study. Int J Cardiol 2016; 204:6-11. [DOI: 10.1016/j.ijcard.2015.11.091] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Revised: 11/13/2015] [Accepted: 11/16/2015] [Indexed: 01/26/2023]
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van 't Sant J, Mast TP, Bos MM, Ter Horst IA, van Everdingen WM, Meine M, Cramer MJ. Echo response and clinical outcome in CRT patients. Neth Heart J 2015; 24:47-55. [PMID: 26643303 PMCID: PMC4692831 DOI: 10.1007/s12471-015-0767-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background Change in left ventricular end-systolic volume (∆LVESV) is the most frequently used surrogate marker in measuring response to cardiac resynchronisation therapy (CRT). We investigated whether ∆LVESV is the best measure to discriminate between a favourable and unfavourable outcome and whether this is equally applicable to non-ischaemic and ischaemic cardiomyopathy. Methods 205 CRT patients (age 65 ± 12 years, 69 % men) were included. At baseline and 6 months echocardiographic studies, exercise testing and laboratory measurements were performed. CRT response was assessed by: ∆LVESV, ∆LV ejection fraction (LVEF), ∆ interventricular mechanical delay, ∆VO2 peak, ∆VE/VCO2, ∆BNP, ∆creatinine, ∆NYHA, and ∆QRS. These were correlated to the occurrence of major adverse cardiac events (MACE) between 6 and 24 months. Results MACE occurred in 19 % of the patients (non-ischaemic: 13 %, ischaemic: 24 %). ∆LVESV remained the only surrogate marker for CRT response for the total population and patients with non-ischaemic cardiomyopathy, showing areas under the curve (AUC) of 0.69 and 0.850, respectively. For ischaemic cardiomyopathy, ∆BNP was the best surrogate marker showing an AUC of 0.66. Conclusion ∆LVESV is an excellent surrogate marker measuring CRT response concerning long-term outcome for non-ischaemic cardiomyopathy. ∆LVESV is not suitable for ischaemic cardiomyopathy in which measuring CRT response remains difficult.
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Affiliation(s)
- J van 't Sant
- Department of Cardiology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.
| | - T P Mast
- Department of Cardiology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - M M Bos
- Department of Cardiology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - I A Ter Horst
- Department of Cardiology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - W M van Everdingen
- Department of Cardiology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - M Meine
- Department of Cardiology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - M J Cramer
- Department of Cardiology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
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Zusterzeel R, Selzman KA, Sanders WE, O’Callaghan KM, Caños DA, Vernooy K, Prinzen FW, Gorgels APM, Strauss DG. Toward Sex-Specific Guidelines for Cardiac Resynchronization Therapy? J Cardiovasc Transl Res 2015; 9:12-22. [DOI: 10.1007/s12265-015-9663-z] [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: 09/02/2015] [Accepted: 11/30/2015] [Indexed: 11/28/2022]
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Rocha EA, Pereira FTM, Abreu JS, Lima JWO, Monteiro MDPM, Rocha Neto AC, Quidute ARP, Goés CVA, Rodrigues Sobrinho CRM, Scanavacca MI. Echocardiographic Predictors of Worse Outcome After Cardiac Resynchronization Therapy. Arq Bras Cardiol 2015; 105:552-9. [PMID: 26351981 PMCID: PMC4693658 DOI: 10.5935/abc.20150108] [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: 05/11/2015] [Accepted: 07/01/2015] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Cardiac resynchronization therapy (CRT) is the recommended treatment by leading global guidelines. However, 30%-40% of selected patients are non-responders. OBJECTIVE To develop an echocardiographic model to predict cardiac death or transplantation (Tx) 1 year after CRT. METHOD Observational, prospective study, with the inclusion of 116 patients, aged 64.89 ± 11.18 years, 69.8% male, 68,1% in NYHA FC III and 31,9% in FC IV, 71.55% with left bundle-branch block, and median ejection fraction (EF) of 29%. Evaluations were made in the pre‑implantation period and 6-12 months after that, and correlated with cardiac mortality/Tx at the end of follow-up. Cox and logistic regression analyses were performed with ROC and Kaplan-Meier curves. The model was internally validated by bootstrapping. RESULTS There were 29 (25%) deaths/Tx during follow-up of 34.09 ± 17.9 months. Cardiac mortality/Tx was 16.3%. In the multivariate Cox model, EF < 30%, grade III/IV diastolic dysfunction and grade III mitral regurgitation at 6‑12 months were independently related to increased cardiac mortality or Tx, with hazard ratios of 3.1, 4.63 and 7.11, respectively. The area under the ROC curve was 0.78. CONCLUSION EF lower than 30%, severe diastolic dysfunction and severe mitral regurgitation indicate poor prognosis 1 year after CRT. The combination of two of those variables indicate the need for other treatment options.
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Rocha EA, Pereira FTM, Abreu JS, Lima JWO, Monteiro MDPM, Rocha Neto AC, Goés CVA, Farias AGP, Rodrigues Sobrinho CRM, Quidute ARP, Scanavacca MI. Development and Validation of Predictive Models of Cardiac Mortality and Transplantation in Resynchronization Therapy. Arq Bras Cardiol 2015; 105:399-409. [PMID: 26559987 PMCID: PMC4633004 DOI: 10.5935/abc.20150093] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2015] [Accepted: 05/06/2015] [Indexed: 01/04/2023] Open
Abstract
Background 30-40% of cardiac resynchronization therapy cases do not achieve favorable
outcomes. Objective This study aimed to develop predictive models for the combined endpoint of cardiac
death and transplantation (Tx) at different stages of cardiac resynchronization
therapy (CRT). Methods Prospective observational study of 116 patients aged 64.8 ± 11.1 years,
68.1% of whom had functional class (FC) III and 31.9% had ambulatory class IV.
Clinical, electrocardiographic and echocardiographic variables were assessed by
using Cox regression and Kaplan-Meier curves. Results The cardiac mortality/Tx rate was 16.3% during the follow-up period of 34.0
± 17.9 months. Prior to implantation, right ventricular dysfunction (RVD),
ejection fraction < 25% and use of high doses of diuretics (HDD) increased the
risk of cardiac death and Tx by 3.9-, 4.8-, and 5.9-fold, respectively. In the
first year after CRT, RVD, HDD and hospitalization due to congestive heart failure
increased the risk of death at hazard ratios of 3.5, 5.3, and 12.5, respectively.
In the second year after CRT, RVD and FC III/IV were significant risk factors of
mortality in the multivariate Cox model. The accuracy rates of the models were
84.6% at preimplantation, 93% in the first year after CRT, and 90.5% in the second
year after CRT. The models were validated by bootstrapping. Conclusion We developed predictive models of cardiac death and Tx at different stages of CRT
based on the analysis of simple and easily obtainable clinical and
echocardiographic variables. The models showed good accuracy and adjustment, were
validated internally, and are useful in the selection, monitoring and counseling
of patients indicated for CRT.
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Witte KKA, Byrom R. Micronutrients for chronic heart failure: end of the road or path to enlightenment? JACC-HEART FAILURE 2015; 2:318-20. [PMID: 24952701 DOI: 10.1016/j.jchf.2014.04.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/14/2014] [Accepted: 04/15/2014] [Indexed: 01/06/2023]
Affiliation(s)
- Klaus K A Witte
- Division of Cardiovascular and Diabetes Research, Leeds Institute of Genetics, Health and Therapeutics, Multidisciplinary Cardiovascular Research Centre, University of Leeds, Leeds, United Kingdom.
| | - Rowenna Byrom
- Division of Cardiovascular and Diabetes Research, Leeds Institute of Genetics, Health and Therapeutics, Multidisciplinary Cardiovascular Research Centre, University of Leeds, Leeds, United Kingdom
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Daly DD, Gold MR. Update on Cardiac Resynchronisation Therapy for Heart Failure. Eur Cardiol 2014; 9:100-103. [PMID: 30310494 DOI: 10.15420/ecr.2014.9.2.100] [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: 11/04/2022] Open
Abstract
Cardiac resynchronisation therapy (CRT) is well accepted therapy for the treatment of symptomatic systolic heart failure in defined patient subgroups. Large clinical trials over the past 20 years have shown that patients with a left ventricular (LV) systolic dysfunction and interventricular conduction delay benefit from this therapy. Recent advances in this field include the expansion indications for CRT to patients with mild heart failure and to those with a mildly depressed ejection fraction that require frequent right ventricular pacing. In addition, although CRT guidelines have included indications in atrial fibrillation, it is now clear that this is most effective when pacing is utilised nearly 100 % of the time, often requiring atrioventricular (AV) junction ablation. Strategies for optimising LV lead placement based on identifying late mechanical contraction or electrical delay are promising for maximising CRT response. Finally, the role of routine AV delay optimisation is no longer recommended based on the results of multicentre trials.
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Affiliation(s)
- David D Daly
- Medical University of South Carolina, Charleston, South Carolina, US
| | - Michael R Gold
- Medical University of South Carolina, Charleston, South Carolina, US
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Lang NN, Badar AA, Pettit SJ, Templeton S, Connelly DT, Gardner RS. Interventricular lead separation is critical for NT-proBNP reduction after cardiac resynchronization therapy. Biomark Med 2014; 8:797-806. [PMID: 25224936 DOI: 10.2217/bmm.13.159] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
AIMS Effective cardiac resynchronization therapy may depend upon the distance between left ventricular (LV) and right ventricular (RV) pacing leads. We assessed the influence of lead separation upon circulating NT-proBNP. MATERIALS & METHODS In total, 132 patients underwent assessment, including NT-proBNP assay, before and after cardiac resynchronization therapy. 3D lead separation was calculated from postero-anterior and lateral chest radiography. RESULTS Lead separation correlated with NT-proBNP reduction (r = 0.25; p = 0.004). Circulating NT-proBNP only fell in those with lead separation in the upper two quartiles. Deteriorating NT-proBNP occurred in 44 patients. Lead separation was less in these patients compared with those with an improvement (corrected 3D lead separation: 148.0 ± 5.38 and 170.5 ± 4.21 mm, respectively; p = 0.0018). CONCLUSION Left ventricular-right ventricular lead separation correlates with postcardiac resynchronization therapy improvements in circulating NT-proBNP, a powerful marker of heart failure status and prognosis. Attention should be paid to achieving maximal lead separation at implantation.
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Affiliation(s)
- Ninian N Lang
- Scottish Advanced Heart Failure Service, Golden Jubilee National Hospital, Agamemnon Street, Clydebank, Glasgow, G81 4DY, UK
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Poglajen G, Sever M, Cukjati M, Cernelc P, Knezevic I, Zemljic G, Haddad F, Wu JC, Vrtovec B. Effects of transendocardial CD34+ cell transplantation in patients with ischemic cardiomyopathy. Circ Cardiovasc Interv 2014; 7:552-9. [PMID: 25097199 DOI: 10.1161/circinterventions.114.001436] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND We investigated the effects of transendocardial CD34(+) cell transplantation in patients with ischemic cardiomyopathy. METHODS AND RESULTS In a prospective crossover study, we enrolled 33 patients with ischemic cardiomyopathy with New York Heart Association class III and left ventricular ejection fraction <40%. In phase 1, patients were treated with medical therapy for 6 months. Thereafter, all patients underwent transendocardial CD34(+) cell transplantation. Peripheral blood CD34(+) cells were mobilized by granulocyte colony stimulating factor, collected via apheresis, and injected transendocardially in the areas of hibernating myocardium. Patients were followed up for 6 months after the procedure (phase 2). Two patients died during phase 1 and none during phase 2. The remaining 31 patients were 85% men, aged 57±6 years. In phase 1, we found no change in left ventricular ejection fraction (from 25.2±6.2% to 27.1±6.6%; P=0.23), N-terminal pro B-type natriuretic peptide (from 3322±3411 to 3672±5165 pg/mL; P=0.75) or 6-minute walk distance (from 373±68 to 411±116 m; P=0.17). In contrast, in phase 2 there was an improvement in left ventricular ejection fraction (from 27.1±6.6% to 34.9±10.9%; P=0.001), increase in 6-minute walk distance (from 411±116 to 496±113 m; P=0.001), and a decrease in N-terminal pro B-type natriuretic peptide (from 3672±5165 to 1488±1847 pg/mL; P=0.04). The average number of injected CD34(+) cells was 90.6±7.5×10(6). Higher doses of CD34(+) cells and a more diffuse distribution of transendocardial cell injections were associated with better clinical response. CONCLUSIONS Transendocardial CD34(+) cell transplantation may be associated with improved left ventricular function, decreased N-terminal pro B-type natriuretic peptide levels, and better exercise capacity in patients with ischemic cardiomyopathy. These effects seem to be particularly pronounced in patients receiving diffusely distributed cell injections and high-dose cell therapy. CLINICAL TRIAL REGISTRATION URL http://www.clinicaltrials.gov. Unique identifier: NCT01350310.
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Affiliation(s)
- Gregor Poglajen
- From the Department of Cardiology, Advanced Heart Failure and Transplantation Center (G.P., G.Z., B.V.), Department of Hematology (M.S., P.C.), and Department of Cardiovascular Surgery (I.K.), University Medical Center Ljubljana, Ljubljana, Slovenia; National Blood Transfusion Institute, Ljubljana, Slovenia (M.C.); and Stanford Cardiovascular Institute, Stanford University School of Medicine, Palo Alto, CA (F.H., J.C.W., B.V.)
| | - Matjaz Sever
- From the Department of Cardiology, Advanced Heart Failure and Transplantation Center (G.P., G.Z., B.V.), Department of Hematology (M.S., P.C.), and Department of Cardiovascular Surgery (I.K.), University Medical Center Ljubljana, Ljubljana, Slovenia; National Blood Transfusion Institute, Ljubljana, Slovenia (M.C.); and Stanford Cardiovascular Institute, Stanford University School of Medicine, Palo Alto, CA (F.H., J.C.W., B.V.)
| | - Marko Cukjati
- From the Department of Cardiology, Advanced Heart Failure and Transplantation Center (G.P., G.Z., B.V.), Department of Hematology (M.S., P.C.), and Department of Cardiovascular Surgery (I.K.), University Medical Center Ljubljana, Ljubljana, Slovenia; National Blood Transfusion Institute, Ljubljana, Slovenia (M.C.); and Stanford Cardiovascular Institute, Stanford University School of Medicine, Palo Alto, CA (F.H., J.C.W., B.V.)
| | - Peter Cernelc
- From the Department of Cardiology, Advanced Heart Failure and Transplantation Center (G.P., G.Z., B.V.), Department of Hematology (M.S., P.C.), and Department of Cardiovascular Surgery (I.K.), University Medical Center Ljubljana, Ljubljana, Slovenia; National Blood Transfusion Institute, Ljubljana, Slovenia (M.C.); and Stanford Cardiovascular Institute, Stanford University School of Medicine, Palo Alto, CA (F.H., J.C.W., B.V.)
| | - Ivan Knezevic
- From the Department of Cardiology, Advanced Heart Failure and Transplantation Center (G.P., G.Z., B.V.), Department of Hematology (M.S., P.C.), and Department of Cardiovascular Surgery (I.K.), University Medical Center Ljubljana, Ljubljana, Slovenia; National Blood Transfusion Institute, Ljubljana, Slovenia (M.C.); and Stanford Cardiovascular Institute, Stanford University School of Medicine, Palo Alto, CA (F.H., J.C.W., B.V.)
| | - Gregor Zemljic
- From the Department of Cardiology, Advanced Heart Failure and Transplantation Center (G.P., G.Z., B.V.), Department of Hematology (M.S., P.C.), and Department of Cardiovascular Surgery (I.K.), University Medical Center Ljubljana, Ljubljana, Slovenia; National Blood Transfusion Institute, Ljubljana, Slovenia (M.C.); and Stanford Cardiovascular Institute, Stanford University School of Medicine, Palo Alto, CA (F.H., J.C.W., B.V.)
| | - François Haddad
- From the Department of Cardiology, Advanced Heart Failure and Transplantation Center (G.P., G.Z., B.V.), Department of Hematology (M.S., P.C.), and Department of Cardiovascular Surgery (I.K.), University Medical Center Ljubljana, Ljubljana, Slovenia; National Blood Transfusion Institute, Ljubljana, Slovenia (M.C.); and Stanford Cardiovascular Institute, Stanford University School of Medicine, Palo Alto, CA (F.H., J.C.W., B.V.)
| | - Joseph C Wu
- From the Department of Cardiology, Advanced Heart Failure and Transplantation Center (G.P., G.Z., B.V.), Department of Hematology (M.S., P.C.), and Department of Cardiovascular Surgery (I.K.), University Medical Center Ljubljana, Ljubljana, Slovenia; National Blood Transfusion Institute, Ljubljana, Slovenia (M.C.); and Stanford Cardiovascular Institute, Stanford University School of Medicine, Palo Alto, CA (F.H., J.C.W., B.V.)
| | - Bojan Vrtovec
- From the Department of Cardiology, Advanced Heart Failure and Transplantation Center (G.P., G.Z., B.V.), Department of Hematology (M.S., P.C.), and Department of Cardiovascular Surgery (I.K.), University Medical Center Ljubljana, Ljubljana, Slovenia; National Blood Transfusion Institute, Ljubljana, Slovenia (M.C.); and Stanford Cardiovascular Institute, Stanford University School of Medicine, Palo Alto, CA (F.H., J.C.W., B.V.).
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Predictors of positive response to cardiac resynchronization therapy. BMC Cardiovasc Disord 2014; 14:55. [PMID: 24779476 PMCID: PMC4016658 DOI: 10.1186/1471-2261-14-55] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2014] [Accepted: 04/23/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Approximately 30% of patients treated with cardiac resynchronization therapy (CRT) do not achieve favourable response. The purpose of the present study was to identify echocardiographic and clinical predictors of a positive response to CRT. METHODS The study included 82 consecutive heart failure (HF) patients in New York Heart Association (NYHA) functional class III or IV with left bundle branch block (LBBB), QRS duration ≥ 120 ms and left ventricular ejection fraction (LVEF) ≤ 35%. Statistical analysis was performed using IBM SPSS statistical software (SPSS v.21.0 for Mac OS X). A p value < 0.05 was considered statistically significant. RESULTS Echocardiographic response was established in 81.6% and clinical response was achieved in 82.9% of patients. Significant univariate predictors of favourable echocardiographic response after 12 months were smaller left ventricular end-diastolic diameter (LVEDD) (odds ratio [OR] 0.89; 95% confidence interval [CI] 0.82 - 0.97, p = 0.01), and smaller left ventricular end-systolic diameter (LVESD) (OR 0.91; 95% CI 0.85 - 0.98, p = 0.01). Lower uric acid concentration was associated with better echocardiographic response (OR 0.99; 95% CI 0.99 - 1.0, p = 0.01). Non-ischemic HF etiology (OR 4.89; 95% CI 1.39 - 17.15, p = 0.01) independently predicted positive clinical response. Multiple stepwise regression analysis demonstrated that LVEDD lower than 75 mm (OR 5.60; 95% confidence interval [CI] 1.36 - 18.61, p = 0.01) was the strongest independent predictor of favourable echocardiographic response. CONCLUSIONS Smaller left ventricular end-diastolic and end-systolic diameters and lower serum uric acid concentration were associated with better response to CRT. Left ventricular end-diastolic diameter and non-ischemic heart failure etiology were the strongest independent predictors of positive response to CRT.
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Brugada J, Brachmann J, Delnoy PP, Padeletti L, Reynolds D, Ritter P, Borri-Brunetto A, Singh JP. Automatic optimization of cardiac resynchronization therapy using SonR-rationale and design of the clinical trial of the SonRtip lead and automatic AV-VV optimization algorithm in the paradym RF SonR CRT-D (RESPOND CRT) trial. Am Heart J 2014; 167:429-36. [PMID: 24655689 DOI: 10.1016/j.ahj.2013.12.007] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2013] [Accepted: 12/03/2013] [Indexed: 11/17/2022]
Abstract
Although cardiac resynchronization therapy (CRT) is effective in most patients with heart failure (HF) and ventricular dyssynchrony, a significant minority of patients (approximately 30%) are non-responders. Optimal atrioventricular and interventricular delays often change over time and reprogramming these intervals might increase CRT effectiveness. The SonR algorithm automatically optimizes atrioventricular and interventricular intervals each week using an accelerometer to measure change in the SonR signal, which was shown previously to correlate with hemodynamic improvement (left ventricular [LV] dP/dtmax). The RESPOND CRT trial will evaluate the effectiveness and safety of the SonR optimization system in patients with HF New York Heart Association class III or ambulatory IV eligible for a CRT-D device. Enrolled patients will be randomized in a 2:1 ratio to either SonR CRT optimization or to a control arm employing echocardiographic optimization. All patients will be followed for at least 24 months in a double-blinded fashion. The primary effectiveness end point will be evaluated for non-inferiority, with a nested test of superiority, based on the proportion of responders (defined as alive, free from HF-related events, with improvements in New York Heart Association class or improvement in Kansas City Cardiomyopathy Questionnaire quality of life score) at 12 months. The required sample size is 876 patients. The two primary safety end points are acute and chronic SonR lead-related complication rates, respectively. Secondary end points include proportion of patients free from death or HF hospitalization, proportion of patients worsened, and lead electrical performance, assessed at 12 months. The RESPOND CRT trial will also examine associated reverse remodeling at 1 year.
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Affiliation(s)
- Josep Brugada
- Hospital Clinic, University of Barcelona, Barcelona, Spain.
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Meta-analysis of symptomatic response attributable to the pacing component of cardiac resynchronization therapy. Eur J Heart Fail 2014; 15:1419-28. [DOI: 10.1093/eurjhf/hft139] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Shanmugam N, Campos AG, Prada-Delgado O, Bizrah M, Valencia O, Jones S, Collinson P, Anderson L. Effect of atrioventricular optimization on circulating N-terminal pro brain natriuretic peptide following cardiac resynchronization therapy. Eur J Heart Fail 2014; 15:534-42. [DOI: 10.1093/eurjhf/hft012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Nesan Shanmugam
- Department of Cardiology; St George's Healthcare NHS Trust; Blackshaw Road London SW17 0QT UK
| | - Ana Garcia Campos
- Department of Cardiology; St George's Healthcare NHS Trust; Blackshaw Road London SW17 0QT UK
| | - Oscar Prada-Delgado
- Department of Cardiology; St George's Healthcare NHS Trust; Blackshaw Road London SW17 0QT UK
| | - Mukhtar Bizrah
- Department of Cardiology; St George's Healthcare NHS Trust; Blackshaw Road London SW17 0QT UK
| | - Oswaldo Valencia
- Department of Cardiology; St George's Healthcare NHS Trust; Blackshaw Road London SW17 0QT UK
| | - Sue Jones
- Department of Cardiology; St George's Healthcare NHS Trust; Blackshaw Road London SW17 0QT UK
| | - Paul Collinson
- Department of Cardiology; St George's Healthcare NHS Trust; Blackshaw Road London SW17 0QT UK
| | - Lisa Anderson
- Department of Cardiology; St George's Healthcare NHS Trust; Blackshaw Road London SW17 0QT UK
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Gierula J, Jamil HA, Byrom R, Joy ER, Cubbon RM, Kearney MT, Witte KK. Pacing-associated left ventricular dysfunction? Think reprogramming first! Heart 2014; 100:765-9. [DOI: 10.1136/heartjnl-2013-304905] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
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Gierula J, Witte KKA. Response to (resynchronization) therapy in chronic heart failure: time for a different approach. Eur J Heart Fail 2014; 16:117-8. [DOI: 10.1002/ejhf.53] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2013] [Accepted: 12/11/2013] [Indexed: 11/10/2022] Open
Affiliation(s)
- John Gierula
- Division of Cardiovascular and Diabetes Research; Leeds Institute of Genetics, Health and Therapeutics Multidisciplinary Cardiovascular Research Centre, University of Leeds; UK
| | - Klaus K. A. Witte
- Division of Cardiovascular and Diabetes Research; Leeds Institute of Genetics, Health and Therapeutics Multidisciplinary Cardiovascular Research Centre, University of Leeds; UK
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Gierula J, Cubbon RM, Jamil HA, Byrom R, Baxter PD, Pavitt S, Gilthorpe MS, Hewison J, Kearney MT, Witte KKA. Cardiac resynchronization therapy in pacemaker-dependent patients with left ventricular dysfunction. Europace 2013; 15:1609-14. [PMID: 23736807 DOI: 10.1093/europace/eut148] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
AIMS Heart failure and left ventricular (LV) systolic dysfunction (LVSD) are common in patients with permanent pacemakers. The aim was to determine if cardiac resynchronization therapy (CRT) at the time of pulse generator replacement (PGR) is of benefit in patients with unavoidable RV pacing and LVSD. METHODS AND RESULTS Fifty patients with unavoidable RV pacing, LVSD, and mild or no symptoms of heart failure, listed for PGR were randomized 1 : 1 to either standard RV-PGR (comparator) or CRT. The primary endpoint was the difference in change in LV ejection fraction (LVEF) between RV-PGR and CRT groups from baseline to 6 months. Secondary endpoints included peak oxygen consumption, quality of life, and N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels. At 6 months there was a difference in change in median (interquartile range) LVEF [9 (6-12) vs. -1.5 (-4.5 to -0.8)%; P < 0.0001] between the CRT and RV-PGR arms. There were also improvements in exercise capacity (P = 0.007), quality of life (P = 0.03), and NT-proBNP (P = 0.007) in those randomized to CRT. After 809 (729-880) days, 17 patients had died or been hospitalized (6 in CRT group and 11 in the comparator RV-PGR group) and two patients in the RV-PGR arm had required CRT for deteriorating heart failure. Patients with standard RV-PGR had more days in hospital during follow-up than those in the CRT group [4 (2-7) vs. 11 (6-16) days; P = 0.047]. CONCLUSION Performing CRT in pacemaker patients with unavoidable RV pacing and LVSD but without severe symptoms of heart failure, at the time of PGR, improves cardiac function, exercise capacity, quality of life, and NT-pro-BNP levels.
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Affiliation(s)
- John Gierula
- Division of Cardiovascular and Diabetes Research, Leeds Institute of Genetics, Health and Therapeutics, Multidisciplinary Cardiovascular Research Centre, University of Leeds, Clarendon Way, Leeds LS2 9JT, UK
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Delnoy PP, Ritter P, Naegele H, Orazi S, Szwed H, Zupan I, Goscinska-Bis K, Anselme F, Martino M, Padeletti L. Association between frequent cardiac resynchronization therapy optimization and long-term clinical response: a post hoc analysis of the Clinical Evaluation on Advanced Resynchronization (CLEAR) pilot study. Europace 2013; 15:1174-81. [PMID: 23493410 PMCID: PMC3718358 DOI: 10.1093/europace/eut034] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Aims The long-term clinical value of the optimization of atrioventricular (AVD) and interventricular (VVD) delays in cardiac resynchronization therapy (CRT) remains controversial. We studied retrospectively the association between the frequency of AVD and VVD optimization and 1-year clinical outcomes in the 199 CRT patients who completed the Clinical Evaluation on Advanced Resynchronization study. Methods and results From the 199 patients assigned to CRT-pacemaker (CRT-P) (New York Heart Association, NYHA, class III/IV, left ventricular ejection fraction <35%), two groups were retrospectively composed a posteriori on the basis of the frequency of their AVD and VVD optimization: Group 1 (n = 66) was composed of patients ‘systematically’ optimized at implant, at 3 and 6 months; Group 2 (n = 133) was composed of all other patients optimized ‘non-systematically’ (less than three times) during the 1 year study. The primary endpoint was a composite of all-cause mortality, heart failure-related hospitalization, NYHA functional class, and Quality of Life score, at 1 year. Systematic CRT optimization was associated with a higher percentage of improved patients based on the composite endpoint (85% in Group 1 vs. 61% in Group 2, P < 0.001), with fewer deaths (3% in Group 1 vs. 14% in Group 2, P = 0.014) and fewer hospitalizations (8% in Group 1 vs. 23% in Group 2, P = 0.007), at 1 year. Conclusion These results further suggest that AVD and VVD frequent optimization (at implant, at 3 and 6 months) is associated with improved long-term clinical response in CRT-P patients.
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Boidol J, Średniawa B, Kowalski O, Szulik M, Mazurek M, Sokal A, Pruszkowska-Skrzep P, Kukulski T, Kalarus Z, Lenarczyk R. Many response criteria are poor predictors of outcomes after cardiac resynchronization therapy: validation using data from the randomized trial. ACTA ACUST UNITED AC 2013; 15:835-44. [DOI: 10.1093/europace/eus390] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Joanna Boidol
- Department of Cardiology, Congenital Heart Disease and Electrotherapy, Silesian Medical University, Silesian Centre for Heart Diseases, Skłodowskiej-Curie Street 9, 41-800 Zabrze, Poland
| | - Beata Średniawa
- Department of Cardiology, Congenital Heart Disease and Electrotherapy, Silesian Medical University, Silesian Centre for Heart Diseases, Skłodowskiej-Curie Street 9, 41-800 Zabrze, Poland
| | - Oskar Kowalski
- Department of Cardiology, Congenital Heart Disease and Electrotherapy, Silesian Medical University, Silesian Centre for Heart Diseases, Skłodowskiej-Curie Street 9, 41-800 Zabrze, Poland
| | - Mariola Szulik
- Department of Cardiology, Congenital Heart Disease and Electrotherapy, Silesian Medical University, Silesian Centre for Heart Diseases, Skłodowskiej-Curie Street 9, 41-800 Zabrze, Poland
| | - Michał Mazurek
- Department of Cardiology, Congenital Heart Disease and Electrotherapy, Silesian Medical University, Silesian Centre for Heart Diseases, Skłodowskiej-Curie Street 9, 41-800 Zabrze, Poland
| | - Adam Sokal
- Department of Cardiology, Congenital Heart Disease and Electrotherapy, Silesian Medical University, Silesian Centre for Heart Diseases, Skłodowskiej-Curie Street 9, 41-800 Zabrze, Poland
| | - Patrycja Pruszkowska-Skrzep
- Department of Cardiology, Congenital Heart Disease and Electrotherapy, Silesian Medical University, Silesian Centre for Heart Diseases, Skłodowskiej-Curie Street 9, 41-800 Zabrze, Poland
| | - Tomasz Kukulski
- Department of Cardiology, Congenital Heart Disease and Electrotherapy, Silesian Medical University, Silesian Centre for Heart Diseases, Skłodowskiej-Curie Street 9, 41-800 Zabrze, Poland
| | - Zbigniew Kalarus
- Department of Cardiology, Congenital Heart Disease and Electrotherapy, Silesian Medical University, Silesian Centre for Heart Diseases, Skłodowskiej-Curie Street 9, 41-800 Zabrze, Poland
| | - Radosław Lenarczyk
- Department of Cardiology, Congenital Heart Disease and Electrotherapy, Silesian Medical University, Silesian Centre for Heart Diseases, Skłodowskiej-Curie Street 9, 41-800 Zabrze, Poland
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Understanding the mechanisms amenable to CRT response: from pre-operative multimodal image data to patient-specific computational models. Med Biol Eng Comput 2013; 51:1235-50. [PMID: 23430328 DOI: 10.1007/s11517-013-1044-7] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2012] [Accepted: 02/02/2013] [Indexed: 01/18/2023]
Abstract
This manuscript describes our recent developments towards better understanding of the mechanisms amenable to cardiac resynchronization therapy response. We report the results from a full multimodal dataset corresponding to eight patients from the euHeart project. The datasets include echocardiography, MRI and electrophysiological studies. We investigate two aspects. The first one focuses on pre-operative multimodal image data. From 2D echocardiography and 3D tagged MRI images, we compute atlas based dyssynchrony indices. We complement these indices with presence and extent of scar tissue and correlate them with CRT response. The second one focuses on computational models. We use pre-operative imaging to generate a patient-specific computational model. We show results of a fully automatic personalized electromechanical simulation. By case-per-case discussion of the results, we highlight the potential and key issues of this multimodal pipeline for the understanding of the mechanisms of CRT response and a better patient selection.
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Duchateau N, Doltra A, Silva E, De Craene M, Piella G, Castel MÁ, Mont L, Brugada J, Frangi AF, Sitges M. Atlas-based quantification of myocardial motion abnormalities: added-value for understanding the effect of cardiac resynchronization therapy. ULTRASOUND IN MEDICINE & BIOLOGY 2012; 38:2186-2197. [PMID: 23069133 DOI: 10.1016/j.ultrasmedbio.2012.08.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/20/2012] [Revised: 07/27/2012] [Accepted: 08/11/2012] [Indexed: 06/01/2023]
Abstract
Statistical atlases may help improving the analysis of cardiac wall-motion abnormalities. This study aims at demonstrating the clinical value of such a method to better understand the effect of cardiac resynchronization therapy (CRT). We compared an atlas of normal septal motion built using apical four-chamber two-dimensional echocardiographic sequences from healthy volunteers with 88 patients undergoing CRT at baseline and at 12 months follow-up. Abnormal motion was quantified locally using a p value based on a statistical distance to normality. Reduction ≥15% in left ventricle end-systolic volume defined CRT response. Responders showed significantly higher reduction of abnormalities (p ≤ 0.001). Non-responders conserved abnormal septal motion at the end of the isovolumic contraction (IVC). A specific inward-outward motion of the septum during IVC predominated in responders and was corrected at follow-up. The method is of interest to characterize patterns of mechanical dyssynchrony and to study the link between their evolution and CRT response.
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Affiliation(s)
- Nicolas Duchateau
- Center for Computational Imaging and Simulation Technologies in Biomedicina, Universitat Pompeu Fabra and Centro de Investigación Biomédica en Red en Bioingeniería, Biomateriales y Nanomedicina, Barcelona, Spain.
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Peak oxygen uptake during cardiopulmonary exercise testing determines response to cardiac resynchronization therapy. J Cardiol 2012; 60:228-35. [DOI: 10.1016/j.jjcc.2012.03.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2011] [Revised: 03/05/2012] [Accepted: 03/07/2012] [Indexed: 11/18/2022]
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Ritter P, Delnoy PPHM, Padeletti L, Lunati M, Naegele H, Borri-Brunetto A, Silvestre J. A randomized pilot study of optimization of cardiac resynchronization therapy in sinus rhythm patients using a peak endocardial acceleration sensor vs. standard methods. Europace 2012; 14:1324-33. [PMID: 22549295 DOI: 10.1093/europace/eus059] [Citation(s) in RCA: 90] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
AIMS Non-response rate to cardiac resynchronization therapy (CRT) might be decreased by optimizing device programming. The Clinical Evaluation on Advanced Resynchronization (CLEAR) study aimed to assess the effects of CRT with automatically optimized atrioventricular (AV) and interventricular (VV) delays, based on a Peak Endocardial Acceleration (PEA) signal system. METHODS AND RESULTS This multicentre, single-blind study randomized patients in a 1 : 1 ratio to CRT optimized either automatically by the PEA-based system, or according to centres' usual practices, mostly by echocardiography. Patients had heart failure (HF) New York Heart Association (NYHA) functional class III/IV, left ventricular ejection fraction (LVEF) <35%, QRS duration >150 or >120 ms with mechanical dyssynchrony. Follow-up was 1 year. The primary endpoint was the proportion of patients who improved their condition at 1 year, based on a composite of all-cause death, HF hospitalizations, NYHA class, and quality of life. In all, 268 patients in sinus rhythm (63% men; mean age: 73.1 ± 9.9 years; mean NYHA: 3.0 ± 0.3; mean LVEF: 27.1 ± 8.1%; and mean QRS duration: 160.1 ± 22.0 ms) were included and 238 patients were randomized, 123 to PEA and 115 to the control group. At 1 year, 76% of patients assigned to PEA were classified as improved, vs. 62% in the control group (P= 0.0285). The percentage of patients with improved NYHA class was significantly (P= 0.0020) higher in the PEA group than in controls. Fatal and non-fatal adverse events were evenly distributed between the groups. CONCLUSION PEA-based optimization of CRT in HF patients significantly increased the proportion of patients who improved with therapy, mainly through improved NYHA class, after 1 year of follow-up.
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Abstract
Cardiac resynchronization therapy reduces mortality and morbidity in heart failure patients with wide QRS and severe impairment of left ventricular systolic function, who are symptomatic despite optimal medical therapy. However, a high percentage of patients fail to show clinical or echocardiographic response to this treatment. Beyond current selection criteria, other elements, such as QRS duration and morphology, concomitant medical therapy, degree of right ventricle dysfunction, myocardial viability, presence of left ventricular dyssynchrony, and associated renal dysfunction, play a crucial role in modulating the response to cardiac resynchronization. Consequently, they should be part of the standard pre-implant evaluation, as they could be used to identify patients who are very unlikely to be responders.
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Nazzal CM, Mulligan LJ, Criscione JC. Efficient characterization of inhomogeneity in contraction strain pattern. Biomech Model Mechanobiol 2011; 11:585-93. [PMID: 21927825 DOI: 10.1007/s10237-011-0335-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2010] [Accepted: 06/29/2011] [Indexed: 11/30/2022]
Abstract
Cardiac dyssynchrony often accompanies patients with heart failure (HF) and can lead to an increase in mortality rate. Cardiac resynchronization therapy (CRT) has been shown to provide substantial benefits to the HF population with ventricular dyssynchrony; however, there still exists a group of patients who do not respond to this treatment. In order to better understand patient response to CRT, it is necessary to quantitatively characterize both electrical and mechanical dyssynchrony. The quantification of mechanical dyssynchrony via characterization of contraction strain field inhomogeneity is the focus of this modeling investigation. Raw data from a 3D finite element (FE) model were received from Roy Kerckhoffs et al. and analyzed in MATLAB. The FE model consisted of canine left and right ventricles coupled to a closed circulation with the effects of the pericardium acting as a pressure on the epicardial surface. For each of three simulations (normal synchronous, SYNC, right ventricular apical pacing, RVA, and left ventricular free wall pacing, LVFW) the Gauss point locations and values were used to generate lookup tables (LUTs) with each entry representing a location in the heart. In essence, we employed piecewise cubic interpolation to generate a fine point cloud (LUTs) from a course point cloud (Gauss points). Strain was calculated in the fiber direction and was then displayed in multiple ways to better characterize strain inhomogeneity. By plotting average strain and standard deviation over time, the point of maximum contraction and the point of maximal inhomogeneity were found for each simulation. Strain values were organized into seven strain bins to show operative strain ranges and extent of inhomogeneity throughout the heart wall. In order to visualize strain propagation, magnitude, and inhomogeneity over time, we created 2D area maps displaying strain over the entire cardiac cycle. To visualize spatial strain distribution at the time point of maximum inhomogeneity, a 3D point cloud was created for each simulation, and a CURE index was calculated. We found that both the RVA and LFVW simulations took longer to reach maximum contraction than the SYNC simulation, while also exhibiting larger disparities in strain values during contraction. Strain in the hoop direction was also analyzed and was found to be similar to the fiber strain results. It was found that our method of analyzing contraction strain pattern yielded more detailed spacial and temporal information about fiber strain in the heart over the cardiac cycle than the more conventional CURE index method. We also observed that our method of strain binning aids in visualization of the strain fields, and in particular, the separation of the mass points into separate images associated with each strain bin allows the strain pattern to be explicitly compartmentalized.
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Affiliation(s)
- Christina M Nazzal
- Department of Biomedical Engineering, Texas A&M University, MS 3120, College Station, TX 77843, USA.
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Fazio S, Carlomagno G. The importance of tricuspid regurgitation and right ventricular overload in ICD/CRT recipients: beside the left, beyond the left. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2011; 34:1181-4. [PMID: 21819432 DOI: 10.1111/j.1540-8159.2011.03189.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Device therapy for advanced heart failure has become increasingly employed in the last 10 years. Several retrospective studies have postulated a harmful effect of implantable cardioverter-defibrillator (ICD) lead placement on tricuspid valve function and right heart hemodynamics, in particular among patients with preexisting pulmonary vascular overload and both left and right ventricular remodeling/dysfunction. This functional hypothesis is also supported by long-term clinical follow-up analyses of ICD and cardiac resynchronization therapy recipients. In this viewpoint, we propose that the possibility of worsening tricuspid regurgitation and consequent hemodynamic deterioration following device implantation should be considered in future studies, as well as in the preimplant evaluation of individual candidates among other clinical factors.
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Affiliation(s)
- Serafino Fazio
- Department of Clinical Medicine, Cardiovascular and Immunological Sciences Federico II University, Naples, Italy.
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McFarlane NJB, Lin X, Zhao Y, Clapworthy GJ, Dong F, Redaelli A, Parodi O, Testi D. Visualization and simulated surgery of the left ventricle in the virtual pathological heart of the Virtual Physiological Human. Interface Focus 2011; 1:374-83. [PMID: 22670207 DOI: 10.1098/rsfs.2010.0040] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2010] [Accepted: 03/03/2011] [Indexed: 12/20/2022] Open
Abstract
Ischaemic heart failure remains a significant health and economic problem worldwide. This paper presents a user-friendly software system that will form a part of the virtual pathological heart of the Virtual Physiological Human (VPH2) project, currently being developed under the European Commission Virtual Physiological Human (VPH) programme. VPH2 is an integrated medicine project, which will create a suite of modelling, simulation and visualization tools for patient-specific prediction and planning in cases of post-ischaemic left ventricular dysfunction. The work presented here describes a three-dimensional interactive visualization for simulating left ventricle restoration surgery, comprising the operations of cutting, stitching and patching, and for simulating the elastic deformation of the ventricle to its post-operative shape. This will supply the quantitative measurements required for the post-operative prediction tools being developed in parallel in the same project.
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Affiliation(s)
- N J B McFarlane
- Centre for Computer Graphics and Visualisation , University of Bedfordshire , Bedfordshire , UK
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