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Ueda N, Oka S, Ishibashi K, Kitai T, Izumi C, Kusano K. Pitfalls of the AdaptivCRT algorithm for effective pacing: Optimization using the EffectivCRT algorithm data. HeartRhythm Case Rep 2024; 10:297-301. [PMID: 38766613 PMCID: PMC11096432 DOI: 10.1016/j.hrcr.2024.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/22/2024] Open
Affiliation(s)
- Nobuhiko Ueda
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Satoshi Oka
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Kohei Ishibashi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Takeshi Kitai
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Chisato Izumi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Kengo Kusano
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
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2
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Manolis AS, Manolis AA, Manolis TA, Melita H. Electrocardiography of cardiac resynchronization therapy: Pitfalls and practical tips. J Cardiovasc Electrophysiol 2021; 32:3228-3244. [PMID: 34664758 DOI: 10.1111/jce.15267] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 09/11/2021] [Accepted: 09/29/2021] [Indexed: 12/25/2022]
Abstract
Cardiac resynchronization therapy (CRT) has been established as an effective mode of therapy in patients with heart failure and concurrent cardiac dyssynchrony, principally in the form of left bundle branch block (LBBB). The widespread use of CRT has ushered in a new landscape in 12-lead electrocardiography (ECG). ECG readings in these patients are most important to guide troubleshooting and also appropriate device programming, as well as discerning and managing nonresponders. A set of four ECG recordings need to accompany each patient with a CRT device, including a baseline ECG and recordings from monochamber (right and left ventricular) and biventricular pacing, which can be compared against a new recording to facilitate the evaluation of proper versus problematic biventricular pacing. Precordial ECG leads V1/2 acquired at the fourth intercostal space and limb leads, I and III, together with a quick assessment of perpendicular leads I and aVF to determine the quadrant of the QRS axis in the hexaxial diagram, may provide the framework for proper ECG interpretation in these patients. This important issue of 12-lead ECG in CRT patients is herein reviewed, pitfalls are pointed out and practical tips are provided for ECG reading to help recognize and manage problems with CRT device function. Furthermore, several pertinent ECG recordings and tabulated data are provided, and an algorithm is suggested that integrates prior algorithms and relevant information from current literature.
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Affiliation(s)
- Antonis S Manolis
- First Department of Cardiology, Athens University School of Medicine, Athens, Greece
| | | | | | - Helen Melita
- Central Laboratories, Onassis Cardiac Surgery Center, Athens, Greece
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3
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Li J, Wang Y, Mai J, Chen S, Liu M, Su C, Chen X, Huang H, Ma Y, Feng C, Jiang J, Liu J, He J, Tang A, Dong Y, Huang X, Chen Y, Wang L. An electrographic AV optimization for the maximum integrative atrioventricular and ventricular resynchronization in CRT. BMC Cardiovasc Disord 2021; 21:288. [PMID: 34112089 PMCID: PMC8193898 DOI: 10.1186/s12872-021-02096-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Accepted: 06/03/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Atrioventricular (AV) delay could affect AV and ventricular synchrony in cardiac resynchronization therapy (CRT). Strategies to optimize AV delay according to optimal AV synchrony (AVopt-AV) or ventricular synchrony (AVopt-V) would potentially be discordant. This study aimed to explore a new AV delay optimization algorithm guided by electrograms to obtain the maximum integrative effects of AV and ventricular resynchronization (opt-AV). METHODS Forty-nine patients with CRT were enrolled. AVopt-AV was measured through the Ritter method. AVopt-V was obtained by yielding the narrowest QRS. The opt-AV was considered to be AVopt-AV or AVopt-V when their difference was < 20 ms, and to be the AV delay with the maximal aortic velocity-time integral between AVopt-AV and AVopt-V when their difference was > 20 ms. RESULTS The results showed that sensing/pacing AVopt-AV (SAVopt-AV/PAVopt-AV) were correlated with atrial activation time (Pend-As/Pend-Ap) (P < 0.05). Sensing/pacing AVopt-V (SAVopt-V/PAVopt-V) was correlated with the intrinsic AV conduction time (As-Vs/Ap-Vs) (P < 0.01). The percentages of patients with more than 20 ms differences between SAVopt-AV/PAVopt-AV and SAVopt-V/PAVopt-V were 62.9% and 57.1%, respectively. Among them, opt-AV was linearly correlated with SAVopt-AV/PAVopt-AV and SAVopt-V/PAVopt-V. The sensing opt-AV (opt-SAV) = 0.1 × SAVopt-AV + 0.4 × SAVopt-V + 70 ms (R2 = 0.665, P < 0.01) and the pacing opt-AV (opt-PAV) = 0.25 × PAVopt-AV + 0.5 × PAVopt-V + 30 ms (R2 = 0.560, P < 0.01). CONCLUSION The SAVopt-AV/PAVopt-AV and SAVopt-V/PAVopt-V were correlated with the atrial activation time and the intrinsic AV conduction interval respectively. Almost half of the patients had a > 20 ms difference between SAVopt-AV/PAVopt-AV and SAVopt-V/PAVopt-V. The opt-AV could be estimated based on electrogram parameters.
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Affiliation(s)
- Jie Li
- Department of Cardiology, The First Affiliated Hospital of Sun Yat-Sen University, No. 58, Zhongshan 2nd Rd, Guangzhou, 510080, Guangdong, People's Republic of China.,Key Laboratory On Assisted Circulation, Ministry of Health, Guangzhou, People's Republic of China
| | - Yuegang Wang
- Department of Cardiology, Nanfang Hospital of Southern Medical University, Guangzhou, People's Republic of China
| | - Jingting Mai
- Department of Cardiology, Sun Yat-Sen Memorial Hospital of Sun Yat-Sen University, No.107, Yanjianxi Rd, Guangzhou, 510080, Guangdong, People's Republic of China
| | - Shilan Chen
- Department of Cardiology, The First Affiliated Hospital of Sun Yat-Sen University, No. 58, Zhongshan 2nd Rd, Guangzhou, 510080, Guangdong, People's Republic of China.,Key Laboratory On Assisted Circulation, Ministry of Health, Guangzhou, People's Republic of China
| | - Menghui Liu
- Department of Cardiology, The First Affiliated Hospital of Sun Yat-Sen University, No. 58, Zhongshan 2nd Rd, Guangzhou, 510080, Guangdong, People's Republic of China.,Key Laboratory On Assisted Circulation, Ministry of Health, Guangzhou, People's Republic of China
| | - Chen Su
- Department of Cardiology, The First Affiliated Hospital of Sun Yat-Sen University, No. 58, Zhongshan 2nd Rd, Guangzhou, 510080, Guangdong, People's Republic of China.,Key Laboratory On Assisted Circulation, Ministry of Health, Guangzhou, People's Republic of China
| | - Xumiao Chen
- Department of Cardiology, The First Affiliated Hospital of Sun Yat-Sen University, No. 58, Zhongshan 2nd Rd, Guangzhou, 510080, Guangdong, People's Republic of China.,Key Laboratory On Assisted Circulation, Ministry of Health, Guangzhou, People's Republic of China
| | - Huiling Huang
- Department of Cardiology, The First Affiliated Hospital of Sun Yat-Sen University, No. 58, Zhongshan 2nd Rd, Guangzhou, 510080, Guangdong, People's Republic of China.,Key Laboratory On Assisted Circulation, Ministry of Health, Guangzhou, People's Republic of China
| | - Yuedong Ma
- Department of Cardiology, The First Affiliated Hospital of Sun Yat-Sen University, No. 58, Zhongshan 2nd Rd, Guangzhou, 510080, Guangdong, People's Republic of China.,Key Laboratory On Assisted Circulation, Ministry of Health, Guangzhou, People's Republic of China
| | - Chong Feng
- Department of Cardiology, The First Affiliated Hospital of Sun Yat-Sen University, No. 58, Zhongshan 2nd Rd, Guangzhou, 510080, Guangdong, People's Republic of China.,Key Laboratory On Assisted Circulation, Ministry of Health, Guangzhou, People's Republic of China
| | - Jingzhou Jiang
- Department of Cardiology, The First Affiliated Hospital of Sun Yat-Sen University, No. 58, Zhongshan 2nd Rd, Guangzhou, 510080, Guangdong, People's Republic of China.,Key Laboratory On Assisted Circulation, Ministry of Health, Guangzhou, People's Republic of China
| | - Jun Liu
- Department of Cardiology, The First Affiliated Hospital of Sun Yat-Sen University, No. 58, Zhongshan 2nd Rd, Guangzhou, 510080, Guangdong, People's Republic of China.,Key Laboratory On Assisted Circulation, Ministry of Health, Guangzhou, People's Republic of China
| | - Jiangui He
- Department of Cardiology, The First Affiliated Hospital of Sun Yat-Sen University, No. 58, Zhongshan 2nd Rd, Guangzhou, 510080, Guangdong, People's Republic of China.,Key Laboratory On Assisted Circulation, Ministry of Health, Guangzhou, People's Republic of China
| | - Anli Tang
- Department of Cardiology, The First Affiliated Hospital of Sun Yat-Sen University, No. 58, Zhongshan 2nd Rd, Guangzhou, 510080, Guangdong, People's Republic of China.,Key Laboratory On Assisted Circulation, Ministry of Health, Guangzhou, People's Republic of China
| | - Yugang Dong
- Department of Cardiology, The First Affiliated Hospital of Sun Yat-Sen University, No. 58, Zhongshan 2nd Rd, Guangzhou, 510080, Guangdong, People's Republic of China.,Key Laboratory On Assisted Circulation, Ministry of Health, Guangzhou, People's Republic of China
| | - Xiaobo Huang
- Department of Cardiology, Nanfang Hospital of Southern Medical University, Guangzhou, People's Republic of China
| | - Yangxin Chen
- Department of Cardiology, Sun Yat-Sen Memorial Hospital of Sun Yat-Sen University, No.107, Yanjianxi Rd, Guangzhou, 510080, Guangdong, People's Republic of China.
| | - Lichun Wang
- Department of Cardiology, The First Affiliated Hospital of Sun Yat-Sen University, No. 58, Zhongshan 2nd Rd, Guangzhou, 510080, Guangdong, People's Republic of China.
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4
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Burri H, Jastrzebski M, Vijayaraman P. Electrocardiographic Analysis for His Bundle Pacing at Implantation and Follow-Up. JACC Clin Electrophysiol 2020; 6:883-900. [DOI: 10.1016/j.jacep.2020.03.005] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Revised: 03/17/2020] [Accepted: 03/18/2020] [Indexed: 12/17/2022]
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5
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Ueda N, Noda T, Ishibashi K, Nakajima K, Kataoka N, Kamakura T, Wada M, Yamagata K, Inoue Y, Miyamoto K, Nagase S, Aiba T, Kanzaki H, Izumi C, Noguchi T, Yasuda S, Kusano K. Efficacy of a Device-Based Continuous Optimization Algorithm for Patients With Cardiac Resynchronization Therapy. Circ J 2019; 84:18-25. [PMID: 31656236 DOI: 10.1253/circj.cj-19-0691] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Cardiac resynchronization therapy (CRT) is less effective in patients with mildly wide QRS or non-left bundle branch block (non-LBBB). A new algorithm of every minute's optimization (adaptive CRT: aCRT algorithm) is effective in patients with CRT devices. This study investigated the clinical effect of the aCRT algorithm, especially in mildly wide QRS (120≤QRS<150 ms) or non-LBBB patients receiving CRT.Methods and Results:This study included 104 CRT patients (48 patients using the aCRT algorithm [adaptive group] and 56 patients not using the aCRT algorithm [non-adaptive group]). The primary endpoint was a composite clinical outcome of cardiac death and/or heart failure (HF) hospitalization. During a median follow-up of 700 days (interquartile range 362-1,173 days), aCRT reduced the risk of the clinical outcome, even in patients with mildly wide QRS or non-LBBB (log-rank P=0.0030 and P=0.0077, respectively) by Kaplan-Meier analysis. Use of the aCRT algorithm was an independent predictor of clinical outcomes in the multivariate analysis (hazard ratio (HR) 0.28, 95% confidence interval (CI): 0.096-0.78, P=0.015), the same as in patients with mildly wide QRS (HR 0.12, 95% CI: 0.006-0.69, P=0.015). CONCLUSIONS The new aCRT algorithm was useful and significantly reduced the risk of the clinical outcome, even in patients with mildly wide QRS.
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Affiliation(s)
- Nobuhiko Ueda
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center.,Department of Advanced Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University
| | - Takashi Noda
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Kohei Ishibashi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Kenzaburo Nakajima
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center.,Department of Advanced Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University
| | - Naoya Kataoka
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Tsukasa Kamakura
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Mitsuru Wada
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center.,Department of Advanced Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University
| | - Kenichiro Yamagata
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Yuko Inoue
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Koji Miyamoto
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Satoshi Nagase
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Takeshi Aiba
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Hideaki Kanzaki
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Chisato Izumi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Teruo Noguchi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Satoshi Yasuda
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center.,Department of Advanced Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University
| | - Kengo Kusano
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
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6
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Kasagawa A, Nakajima I, Izumo M, Nakayama Y, Yamada M, Takano M, Matsuda H, Furukawa T, Miyazaki H, Harada T, Akashi YJ. Novel Device-Based Algorithm Provides Optimal Hemodynamics During Exercise in Patients With Cardiac Resynchronization Therapy. Circ J 2019; 83:2002-2009. [PMID: 31462585 DOI: 10.1253/circj.cj-19-0512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND An adaptive cardiac resynchronization therapy (aCRT) algorithm has been described for synchronized left ventricular (LV) pacing and continuous optimization of cardiac resynchronization therapy (CRT). However, there are few algorithmic data on the effect of changes during exercise.Methods and Results:We enrolled 27 patients with availability of the aCRT algorithm. Eligible patients were manually programmed to optimal atrioventricular (AV) and interventricular (VV) delays by using echocardiograms at rest or during 2 stages of supine bicycle exercise. We compared the maximum cardiac output between manual echo-optimization and aCRT-on during each phase. After initiating exercise, the optimal AV delay progressively shortened (P<0.05) with incremental exercise levels. The manual-optimized settings and aCRT resulted in similar cardiac performance, as demonstrated by a high concordance correlation coefficient between the LV outflow tract velocity time integral (LVOT-VTI) during each exercise stage (Ex.1: r=0.94 P<0.0008, Ex.2: r=0.88 P<0.001, respectively). Synchronized LV-only pacing in patients with normal AV conduction could provide a higher LVOT-VTI as compared with manual-optimized conventional biventricular pacing at peak exercise (P<0.05). CONCLUSIONS The aCRT algorithm was physiologically sound during exercise by patients.
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Affiliation(s)
- Akira Kasagawa
- Division of Cardiology, St. Marianna University School of Medicine
| | - Ikutaro Nakajima
- Division of Cardiology, St. Marianna University School of Medicine
| | - Masaki Izumo
- Division of Cardiology, St. Marianna University School of Medicine
| | - Yui Nakayama
- Division of Cardiology, St Marianna University School of Medicine, Yokohama City Seibu Hospital
| | - Marika Yamada
- Division of Cardiology, St. Marianna University School of Medicine
| | - Makoto Takano
- Division of Cardiology, St. Marianna University School of Medicine
| | - Hisao Matsuda
- Division of Cardiology, St Marianna University School of Medicine, Yokohama City Seibu Hospital
| | - Toshiyuki Furukawa
- Division of Cardiology, St. Marianna University School of Medicine, Toyoko Hospital
| | | | - Tomoo Harada
- Division of Cardiology, St. Marianna University School of Medicine
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7
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Nagata Y, Nakagawa Y, Takeda Y, Emoto K, Kinoshita M, Chikata A, Maruyama M, Usuda K. Adaptive cardiac resynchronization therapy for dilated cardiomyopathy with functional mitral regurgitation. J Arrhythm 2017; 33:514-517. [PMID: 29021862 PMCID: PMC5634678 DOI: 10.1016/j.joa.2017.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2016] [Revised: 03/29/2017] [Accepted: 04/11/2017] [Indexed: 11/29/2022] Open
Abstract
We report the case of a man in his 60s who had dilated cardiomyopathy with severe functional mitral regurgitation. Four years after a cardiac resynchronization therapy (CRT) device with an implantable cardioverter defibrillator was implanted, this device was replaced with an adaptive CRT device because of battery consumption. Seven months after replacement of this device, the left ventricular pacing to right ventricular activation and the atrioventricular delay from automatic adjustments contributed to less functional mitral regurgitation. The findings from our case suggest that optimal CRT, by measuring intracardiac conduction parameters, is effective for functional mitral regurgitation.
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8
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Zhao L, Zhao L, Pu L, Hua B, Wang Y, Li S, Li Q, Guo T. Left Univentricular Pacing by Rate-Adaptive Atrioventricular Delay in Treatment of Chronic Heart Failure. Med Sci Monit 2017; 23:3971-3980. [PMID: 28814710 PMCID: PMC5572785 DOI: 10.12659/msm.904348] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Cardiac resynchronization therapy (CRT) is efficacious in the treatment of chronic heart failure (CHF); however, because it is non-physiological, some patients are unresponsive. The present study used rate-adaptive atrioventricular delay (RAAVD) to track the physiological atrioventricular delay and investigated the effects of left univentricular pacing on CRT. Material/Methods Patients with CHF fulfilling the indication of CRT Class I were categorized into a left univentricular pacing by RAAVD group and a standard biventricular pacing group. Preoperative and postoperative electrocardiography QRS duration, echocardiographic indicators, quality of life, cardiac function, and annual treatment cost were estimated. The standard deviation (RS/R-SD5) of the S/R ratio in lead V1 at 5 heart rate segments in the left univentricular pacing by RAAVD was calculated, and the accuracy of RAAVD in tracking the physiological AV delay was evaluated. Results The comparison between the left univentricular pacing by RAAVD group and the standard biventricular pacing group after operation showed a significantly reduced QRS duration (137±11 vs. 144±11 ms, P<0.05), increased AVVTI (21.84±2.25 vs. 20.45±2.12 cm, P<0.05), reduced IVMD (64.27±12.29 vs. 71.39±13.64 ms, P<0.05), decreased MRA (3.09±1.12 vs. 3.73±1.19 cm2, P<0.05), and reduced average annual treatment cost (1.30±0.1 vs. 2.20±0.2 million Yuan, P<0.05). The RS/R-SD5 in the left univentricular pacing by RAAVD group was negatively correlated with improvements in cardiac function (r=−0.394, P=0.031). Conclusions Left univentricular pacing by RAAVD has treatment effects similar to those of standard biventricular pacing, and is an economically and physiologically effective method for biventricular systolic resynchronization in the treatment of CHF.
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Affiliation(s)
- Lulu Zhao
- Department of Cardiology, The First Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, China (mainland)
| | - Ling Zhao
- Department of Cardiology, The First Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, China (mainland)
| | - Lijin Pu
- Department of Cardiology, The First Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, China (mainland)
| | - Baotong Hua
- Department of Cardiology, The First Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, China (mainland)
| | - Yu Wang
- Department of Cardiology, The First Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, China (mainland)
| | - Shumin Li
- Department of Cardiology, The First Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, China (mainland)
| | - Qing Li
- Department of Cardiology, The First Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, China (mainland)
| | - Tao Guo
- Department of Cardiology, The First Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, China (mainland)
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9
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Burri H, Prinzen FW, Gasparini M, Leclercq C. Left univentricular pacing for cardiac resynchronization therapy. Europace 2017; 19:912-919. [PMID: 28339579 DOI: 10.1093/europace/euw179] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
This review describes the rationale and published evidence for left univentricular pacing for cardiac resynchronization therapy, gives an overview of the existing optimization algorithms featuring this mode, and discusses future perspectives.
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Affiliation(s)
- Haran Burri
- Cardiology Department, University Hospital of Geneva, Geneva, Switzerland
| | - Frits W Prinzen
- Department of Physiology, Maastricht University, Maastricht, The Netherlands
| | - Maurizio Gasparini
- EP and Pacing Unit, Humanitas Research Hospital IRCCS, Rozzano, Milano, Italy
| | - Christophe Leclercq
- Department of Cardiology, Service de Cardiologie et Maladies Vasculaires Rennes University Hospital, Rennes, France
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10
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Daoud GE, Houmsse M. Cardiac resynchronization therapy pacemaker: critical appraisal of the adaptive CRT-P device. MEDICAL DEVICES-EVIDENCE AND RESEARCH 2016; 9:19-25. [PMID: 26848278 PMCID: PMC4723027 DOI: 10.2147/mder.s77940] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Cardiac resynchronization therapy (CRT) is an effective and well-established therapy for patients suffering with heart failure, left ventricular (LV) systolic dysfunction (ejection fraction ≤35%), and electrical dyssynchrony, demonstrated by a surface QRS duration of ≥120 ms. Patients undergoing treatment with CRT have shown significant improvement in functional class, quality of life, LV ejection fraction, exercise capacity, hemodynamics, and reverse remodeling of LV, and ultimately, morbidity and mortality. However, 30%–40% of patients who receive a CRT device may not show improvement, and they are termed as non responders. The nonresponders have a poor prognosis; several methods have been developed to try to enhance response to CRT. Echocardiography-guided optimization of CRT has not resulted in significant clinical benefit, since it is done at rest with the patient in supine position. An ideal optimization strategy would provide continuous monitoring and adjustment of device pacing to provide maximal cardiac resynchronization, under a multitude of physiologic states. Intrinsic activation of the right ventricle (RV) with paced activation of the RV, even in the setting of biventricular (BiV) pacing, may result in an adverse effect on cardiac performance. With this physiology, the use of LV-only pacing may be preferred and may enhance CRT. Adaptive CRT is a novel device-based algorithm that was designed to achieve patient-specific adjustment in CRT so as to provide appropriate BiV pacing or LV-only pacing. This article will review the goals of CRT optimization, and implementation and outcomes associated with adaptive CRT.
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Affiliation(s)
- Georges E Daoud
- Department of the Biomedical Research, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Mahmoud Houmsse
- Division of Cardiovascular Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
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11
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Fukuhara K, Okura H, Koyama T, Kume T, Neishi Y, Hayashida A, Yoshida K. Feasibility of a novel atrioventricular delay optimization method using transmitral and pulmonary venous flow in patients with sequential ventricular pacing or cardiac resynchronization therapy. J Echocardiogr 2015; 13:52-8. [PMID: 26069448 PMCID: PMC4454827 DOI: 10.1007/s12574-014-0237-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2014] [Revised: 11/07/2014] [Accepted: 11/25/2014] [Indexed: 11/28/2022]
Abstract
Background Although several echo-Doppler methods were proposed to optimize atrioventricular (AV) delay in patients with sequential ventricular pacing, “echo-guided” AV optimization has not been widely adopted clinically. A combination of trasmitral flow (TMF) and pulmonary venous flow (PVF) measurements may be beneficial to further optimize AV delay to achieve better cardiac function. The aim of this study was to assess the feasibility and usefulness of AV delay optimization by combined use of TMF and PVF. Methods A total of 32 patients after sequential ventricular pacemaker implantation were enrolled and studied. The optimal AV delay was defined as the timing to minimize the duration between PVF reversal (a) wave and the duration of the “A” wave of TMF. Stroke volume was measured at the “optimized” AV delay (AVDOPT) and was compared with that obtained at shorter (AVDOPT − 50 ms) and longer (AVDOPT + 50 ms) AV delays. Results AV optimization was feasible in 27 of 32 patients (87 %). Stroke volume at AVDOPT was significantly higher than that at shorter or longer AV delay (63 ± 18 ml vs. 57 ± 15 ml vs. 56 ± 16 ml, P = 0.001). Conclusions AV delay optimization using TMF and PV flow was feasible. Usefulness of this method requires further investigation with a larger study population.
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Affiliation(s)
- Kenzo Fukuhara
- Division of Cardiology, Kawasaki Medical School, Kurashiki, Japan
| | - Hiroyuki Okura
- Division of Cardiology, Kawasaki Medical School, Kurashiki, Japan
| | - Terumasa Koyama
- Division of Cardiology, Kawasaki Medical School, Kurashiki, Japan
| | - Teruyoshi Kume
- Division of Cardiology, Kawasaki Medical School, Kurashiki, Japan
| | - Yoji Neishi
- Division of Cardiology, Kawasaki Medical School, Kurashiki, Japan
| | | | - Kiyoshi Yoshida
- Division of Cardiology, Kawasaki Medical School, Kurashiki, Japan
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12
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Guo T, Li R, Zhang L, Luo Z, Zhao L, Yang J, Pu L, Hua B. Biventricular Pacing With Ventricular Fusion by Intrinsic Activation in Cardiac Resynchronization Therapy. Int Heart J 2015; 56:293-7. [DOI: 10.1536/ihj.14-260] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Tao Guo
- Department of Cardiology, the First Affiliated Hospital of Kunming Medical University
| | - Ruijie Li
- Department of Cardiology, the First Affiliated Hospital of Kunming Medical University
| | - Limei Zhang
- Department of Cardiology, the First Affiliated Hospital of Kunming Medical University
| | - Zhiling Luo
- Department of Cardiology, the First Affiliated Hospital of Kunming Medical University
| | - Ling Zhao
- Department of Cardiology, the First Affiliated Hospital of Kunming Medical University
| | - Jun Yang
- Department of Cardiology, the First Affiliated Hospital of Kunming Medical University
| | - Lijin Pu
- Department of Cardiology, the First Affiliated Hospital of Kunming Medical University
| | - Baotong Hua
- Department of Cardiology, the First Affiliated Hospital of Kunming Medical University
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Houmsse M, Abraham WT. Continuously adjusting CRT therapy: clinical impact of adaptive cardiac resynchronization therapy. Expert Rev Cardiovasc Ther 2014; 12:541-8. [DOI: 10.1586/14779072.2014.901150] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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van Deursen CJ, Blaauw Y, Witjens MI, Debie L, Wecke L, Crijns HJ, Prinzen FW, Vernooy K. The value of the 12-lead ECG for evaluation and optimization of cardiac resynchronization therapy in daily clinical practice. J Electrocardiol 2014; 47:202-11. [DOI: 10.1016/j.jelectrocard.2014.01.007] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2013] [Indexed: 01/30/2023]
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Sohaib SMA, Whinnett ZI, Ellenbogen KA, Stellbrink C, Quinn TA, Bogaard MD, Bordachar P, van Gelder BM, van Geldorp IE, Linde C, Meine M, Prinzen FW, Turcott RG, Spotnitz HM, Wichterle D, Francis DP. Cardiac resynchronisation therapy optimisation strategies: systematic classification, detailed analysis, minimum standards and a roadmap for development and testing. Int J Cardiol 2013; 170:118-31. [PMID: 24239155 DOI: 10.1016/j.ijcard.2013.10.069] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2013] [Revised: 09/19/2013] [Accepted: 10/19/2013] [Indexed: 01/23/2023]
Abstract
In this article an international group of CRT specialists presents a comprehensive classification system for present and future schemes for optimising CRT. This system is neutral to the measurement technology used, but focuses on little-discussed quantitative physiological requirements. We then present a rational roadmap for reliable cost-effective development and evaluation of schemes. A widely recommended approach for AV optimisation is to visually select the ideal pattern of transmitral Doppler flow. Alternatively, one could measure a variable (such as Doppler velocity time integral) and "pick the highest". More complex would be to make measurements across a range of settings and "fit a curve". In this report we provide clinicians with a critical approach to address any recommendations presented to them, as they may be many, indistinct and conflicting. We present a neutral scientific analysis of each scheme, and equip the reader with simple tools for critical evaluation. Optimisation protocols should deliver: (a) singularity, with only one region of optimality rather than several; (b) blinded test-retest reproducibility; (c) plausibility; (d) concordance between independent methods; and (e) transparency, with all steps open to scrutiny. This simple information is still not available for many optimisation schemes. Clinicians developing the habit of asking about each property in turn will find it easier to win now down the broad range of protocols currently promoted. Expectation of a sophisticated enquiry from the clinical community will encourage optimisation protocol-designers to focus on testing early (and cheaply) the basic properties that are vital for any chance of long term efficacy.
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Affiliation(s)
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- National Heart & Lung Institute, Imperial College London, UK.
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Singh JP, Abraham WT, Chung ES, Rogers T, Sambelashvili A, Coles JA, Martin DO. Clinical response with adaptive CRT algorithm compared with CRT with echocardiography-optimized atrioventricular delay: a retrospective analysis of multicentre trials. Europace 2013; 15:1622-8. [PMID: 24014804 DOI: 10.1093/europace/eut107] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
AIMS Adaptive cardiac resynchronization therapy (aCRT) is a novel algorithm for CRT pacing that provides automatic ambulatory selection between synchronized left ventricular (LV) or bi-ventricular (BiV) pacing and optimization of atrioventricular (AV) and inter-ventricular (VV) delays based on periodic measurement of intrinsic conduction. We aimed to compare the clinical response between aCRT and standard CRT in historical trials. METHODS AND RESULTS The treatment arm of the aCRT trial was compared with a pooled historical control (HC) derived from the CRT arms of four clinical trials (MIRACLE, MIRACLE ICD, PROSPECT, and InSync III Marquis) with respect to the proportion of patients who had an improved clinical composite score (CCS) at the 6-month follow-up. Patients in the HC underwent echocardiography-guided AV optimization after the implant. A propensity score model was used to adjust for 22 potential baseline confounders of the effect of CRT. Patients were stratified into quintiles according to the propensity score and the adjusted absolute treatment effect was obtained by averaging estimates across these quintiles. The propensity score model included 751 patients (aCRT: 266, historical trials: 485). The adjusted absolute difference in percent improved in CCS between the aCRT and HC arms was 11.9% [95% confidence interval (CI): 2.7-19.2%] favouring aCRT. The patients in the aCRT group were significantly more likely to have an improved CCS than the patients in the HC (odds ratio = 1.65, 95% CI: 1.1-2.5). CONCLUSION The aCRT algorithm may be associated with additional improvement in clinical response compared with historical CRT with echocardiographic AV optimization.
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Affiliation(s)
- Jagmeet P Singh
- Massachusetts General Hospital Heart Center, Harvard Medical School, 55 Fruit St., Boston, MA 02114, USA
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Pasipoularides A. Evaluation of right and left ventricular diastolic filling. J Cardiovasc Transl Res 2013; 6:623-39. [PMID: 23585308 PMCID: PMC3713169 DOI: 10.1007/s12265-013-9461-4] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2013] [Accepted: 03/27/2013] [Indexed: 01/08/2023]
Abstract
A conceptual fluid-dynamics framework for diastolic filling is developed. The convective deceleration load (CDL) is identified as an important determinant of ventricular inflow during the E wave (A wave) upstroke. Convective deceleration occurs as blood moves from the inflow anulus through larger-area cross-sections toward the expanding walls. Chamber dilatation underlies previously unrecognized alterations in intraventricular flow dynamics. The larger the chamber, the larger becomes the endocardial surface and the CDL. CDL magnitude affects strongly the attainable E wave (A wave) peak. This underlies the concept of diastolic ventriculoannular disproportion. Large vortices, whose strength decreases with chamber dilatation, ensue after the E wave peak and impound inflow kinetic energy, averting an inflow-impeding, convective Bernoulli pressure rise. This reduces the CDL by a variable extent depending on vortical intensity. Accordingly, the filling vortex facilitates filling to varying degrees, depending on chamber volume. The new framework provides stimulus for functional genomics research, aimed at new insights into ventricular remodeling.
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MESH Headings
- Animals
- Biomechanical Phenomena
- Diastole
- Disease Progression
- Genetic Predisposition to Disease
- Genomics
- Heart Failure/genetics
- Heart Failure/physiopathology
- Humans
- Hypertrophy, Left Ventricular/genetics
- Hypertrophy, Left Ventricular/physiopathology
- Hypertrophy, Right Ventricular/genetics
- Hypertrophy, Right Ventricular/physiopathology
- Models, Cardiovascular
- Phenotype
- Stroke Volume
- Ventricular Dysfunction, Left/genetics
- Ventricular Dysfunction, Left/physiopathology
- Ventricular Dysfunction, Right/genetics
- Ventricular Dysfunction, Right/physiopathology
- Ventricular Function, Left/genetics
- Ventricular Function, Right/genetics
- Ventricular Pressure
- Ventricular Remodeling
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Affiliation(s)
- Ares Pasipoularides
- Department of Surgery, Duke University School of Medicine, HAFS-7th floor, DUMC 3704, Durham, NC 27710, USA.
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Birnie D, Lemke B, Aonuma K, Krum H, Lee KLF, Gasparini M, Starling RC, Milasinovic G, Gorcsan J, Houmsse M, Abeyratne A, Sambelashvili A, Martin DO. Clinical outcomes with synchronized left ventricular pacing: analysis of the adaptive CRT trial. Heart Rhythm 2013; 10:1368-74. [PMID: 23851059 DOI: 10.1016/j.hrthm.2013.07.007] [Citation(s) in RCA: 87] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2013] [Indexed: 01/14/2023]
Abstract
BACKGROUND Acute studies have suggested that left ventricular pacing (LVP) may have benefits over biventricular pacing (BVP). The adaptive cardiac resynchronization therapy (aCRT) algorithm provides LVP synchronized to produce fusion with the intrinsic activation when the intrinsic atrioventricular (AV) interval is normal. The randomized double-blind adaptive cardiac resynchronization therapy trial demonstrated noninferiority of the aCRT algorithm compared to echocardiography-optimized BVP (control). OBJECTIVE To examine whether synchronized LVP (sLVP) resulted in better clinical outcomes. METHODS First, stratification by percent sLVP (%sLVP) and multivariate Cox proportional hazards model was used to assess the relationship between %sLVP and clinical outcomes. Second, outcomes were compared between patients in the aCRT arm (n = 318) and control patients (n = 160) stratified by intrinsic AV interval at randomization. RESULTS In the aCRT arm, %sLVP ≥50% (n = 142) was independently associated with a decreased risk of death or heart failure hospitalization (hazard ratio 0.49; 95% confidence interval 0.28-0.85; P = .012) compared with %sLVP <50% (n = 172). A greater proportion of patients with %sLVP ≥50% improved in Packer's clinical composite score at 6-month (82% vs. 68%; P = .002) and 12-month (80% vs. 62%; P = .0006) follow-ups compared to controls. In the subgroup with normal AV (n = 241), there was a lower risk of death or heart failure hospitalization (hazard ratio 0.52; 95% confidence interval 0.27-0.98; P = .044) with the aCRT algorithm. A greater proportion of patients in the aCRT arm improved in the clinical composite score at 6-month (81% vs. 69%; P = .041) and 12-month (77% vs. 66%; P = .076) follow-ups compared to controls. CONCLUSIONS Higher %sLVP was independently associated with superior clinical outcomes. In patients with normal AV conduction, the aCRT algorithm provided mostly sLVP and demonstrated better clinical outcomes compared to echocardiography-optimized BVP.
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Affiliation(s)
- David Birnie
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada.
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Martin DO, Lemke B, Birnie D, Krum H, Lee KLF, Aonuma K, Gasparini M, Starling RC, Milasinovic G, Rogers T, Sambelashvili A, Gorcsan J, Houmsse M. Investigation of a novel algorithm for synchronized left-ventricular pacing and ambulatory optimization of cardiac resynchronization therapy: results of the adaptive CRT trial. Heart Rhythm 2012; 9:1807-14. [PMID: 22796472 DOI: 10.1016/j.hrthm.2012.07.009] [Citation(s) in RCA: 186] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2012] [Indexed: 12/16/2022]
Abstract
BACKGROUND In patients with sinus rhythm and normal atrioventricular conduction, pacing only the left ventricle with appropriate atrioventricular delays can result in superior left ventricular and right ventricular function compared with standard biventricular (BiV) pacing. OBJECTIVE To evaluate a novel adaptive cardiac resynchronization therapy ((aCRT) algorithm for CRT pacing that provides automatic ambulatory selection between synchronized left ventricular or BiV pacing with dynamic optimization of atrioventricular and interventricular delays. METHODS Patients (n = 522) indicated for a CRT-defibrillator were randomized to aCRT vs echo-optimized BiV pacing (Echo) in a 2:1 ratio and followed at 1-, 3-, and 6-month postrandomization. RESULTS The study met all 3 noninferiority primary objectives: (1) the percentage of aCRT patients who improved in their clinical composite score at 6 months was at least as high in the aCRT arm as in the Echo arm (73.6% vs 72.5%, with a noninferiority margin of 12%; P = .0007); (2) aCRT and echo-optimized settings resulted in similar cardiac performance, as demonstrated by a high concordance correlation coefficient between aortic velocity time integrals at aCRT and Echo settings at randomization (concordance correlation coefficient = 0.93; 95% confidence interval 0.91-0.94) and at 6-month postrandomization (concordance correlation coefficient = 0.90; 95% confidence interval 0.87-0.92); and (3) aCRT did not result in inappropriate device settings. There were no significant differences between the arms with respect to heart failure events or ventricular arrhythmia episodes. Secondary end points showed similar benefit, and right-ventricular pacing was reduced by 44% in the aCRT arm. CONCLUSIONS The aCRT algorithm is safe and at least as effective as BiV pacing with comprehensive echocardiographic optimization.
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Affiliation(s)
- David O Martin
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio 44195, USA.
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Krum H, Lemke B, Birnie D, Lee KLF, Aonuma K, Starling RC, Gasparini M, Gorcsan J, Rogers T, Sambelashvili A, Kalmes A, Martin D. A novel algorithm for individualized cardiac resynchronization therapy: rationale and design of the adaptive cardiac resynchronization therapy trial. Am Heart J 2012; 163:747-752.e1. [PMID: 22607850 DOI: 10.1016/j.ahj.2012.02.007] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2011] [Accepted: 02/02/2012] [Indexed: 11/18/2022]
Abstract
BACKGROUND The magnitude of benefit of cardiac resynchronization therapy (CRT) varies significantly among its recipients; approximately 30% of CRT patients do not report clinical improvement. Optimization of CRT pacing parameters can further improve cardiac function, both acutely and chronically. Echocardiographic optimization is used in clinical practice, but it is time and resource consuming. In addition, optimal settings at rest may change later with activity or cardiac remodeling. The adaptive CRT (aCRT) algorithm was designed to provide automatic ambulatory adjustment of CRT pacing configuration (left ventricular or biventricular pacing) and device delays based on periodic measurement of electrical conduction intervals. METHODS The aCRT algorithm is currently undergoing evaluation in a prospective, randomized, double-blinded, worldwide clinical trial. The trial enrolled 522 patients, who satisfied standard clinical indications for a CRT device. Within 2 weeks after the implant, the patients were randomized to aCRT versus echo-optimized biventricular pacing (Echo) settings in 2:1 ratio and followed up at 1-, 3-, 6-, and 12-month postrandomization. The noninferiority primary trial objectives at 6-month postrandomization are to demonstrate that (a) the percentage of aCRT patients who improved in their clinical composite score is at least as high as the percentage of Echo patients; (b) cardiac performance as assessed by echocardiography is similar when using aCRT settings versus echo-optimized settings; and (c) aCRT does not result in inappropriate device settings. First and last patient enrollments occurred in November 2009 and December 2010, respectively. CONCLUSIONS The safety and efficacy of the aCRT algorithm will be evaluated in this ongoing clinical trial.
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Affiliation(s)
- Henry Krum
- Department of Epidemiology & Preventive Medicine, Monash Centre of Cardiovascular Research & Education in Therapeutics, 89 Commercial Road, Melbourne, VIC 3004 Australia.
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