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Zou JH, Hua BT, Shao XX, Wang C, Li H, Lu YN, Tian X, Li ZX, Pu LJ, Wang J. Redefining left bundle branch block from high-density electroanatomical mapping. Int J Cardiol 2024; 402:131830. [PMID: 38320669 DOI: 10.1016/j.ijcard.2024.131830] [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: 09/26/2023] [Revised: 01/13/2024] [Accepted: 02/01/2024] [Indexed: 02/08/2024]
Abstract
BACKGROUND The existing ECG criteria for diagnosing left bundle branch block (LBBB) are insufficient to distinguish between true and false blocks accurately. METHODS We hypothesized that the notch width of the QRS complex in the lateral leads (I, avL, V5, V6) on the LBBB-like ECG could further confirm the diagnosis of true complete left bundle branch block (t-LBBB). We conducted high-density, three-dimensional electroanatomical mapping in the cardiac chambers of 37 patients scheduled to undergo CRT. These patients' preoperative electrocardiograms met the ACC/AHA/HRS guidelines for the diagnosis of complete LBBB. If the left bundle branch potential could be mapped from the base of the heart to the apex on the left ventricular septum, it was defined as a false complete left bundle branch block (f-LBBB). Otherwise, it was categorized as a t-LBBB. We conducted a comparative analysis between the two groups, considering the clinical characteristics, real-time correspondence between the spread of ventricular electrical excitation and the QRS wave, QRS notch width of the lateral leads (I, avL, V5, V6), and the notch width/left ventricular end-diastolic diameter (Nw/LVd) ratio. We performed the ROC correlation analysis of Nw/LVd and t-LBBB to determine the sensitivity and specificity for diagnostic authenticity. RESULTS Twenty-five patients were included in the t-LBBB group, while 12 patients were assigned to the f-LBBB group. Within the t-LBBB group, the first peak of the QRS notch correlated with the depolarization of the right ventricle and septum, the trough corresponded to the depolarization of the left ventricle across the left ventricle, and the second peak aligned with the depolarization of the left ventricular free wall. In contrast, within the f-LBBB group, the first peak coincided with the depolarization of the right ventricle and a majority of the left ventricle, the second peak occurred due to the depolarization of the latest, locally-activated myocardium in the left ventricle, and the trough was a result of delayed activation of the left ventricle that did not align with the usual peak timing. The QRS notch width (45.2 ± 12.3 ms vs. 52.5 ± 9.2 ms, P < 0.05) and the Nw/LVd ratio (0.65 ± 0.19 ms/mm vs. 0.81 ± 0.17 ms/mm, P < 0.05) were compared between the two groups. After conducting the ROC correlation analysis, a sensitivity of 56% and a specificity of 91.7% for diagnosing t-LBBB using Nw/LVd were obtained. CONCLUSION By utilizing the current diagnostic criteria for LBBB, an increased Nw/LVd value can enhance the effectiveness of diagnosing LBBB.
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Affiliation(s)
- Jun-Hua Zou
- The first Department of Cardiology, the First Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, China
| | - Bao-Tong Hua
- The third Department of Cardiology, the First Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, China
| | - Xiao-Xia Shao
- The third Department of Cardiology, the First Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, China
| | - Chao Wang
- The first Department of Cardiology, the First Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, China
| | - Hao Li
- The third Department of Cardiology, the First Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, China
| | - Ya-Nan Lu
- The first Department of Cardiology, the First Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, China
| | - Xin Tian
- The first Department of Cardiology, the First Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, China
| | - Zhi-Xuan Li
- The first Department of Cardiology, the First Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, China
| | - Li-Jin Pu
- The first Department of Cardiology, the First Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, China.
| | - Jing Wang
- The first Department of Cardiology, the First Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, China.
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Liu X, Li M, Chen J, Wu J, Zhang L, Hu J, Li F, Fan X, Yang H, Yan L, Liu J. Association between left bundle branch block and ventricular septal mid-wall fibrosis in patients with preserved left ventricular ejection fraction. J Electrocardiol 2024; 83:21-25. [PMID: 38241779 DOI: 10.1016/j.jelectrocard.2024.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2023] [Revised: 11/29/2023] [Accepted: 01/07/2024] [Indexed: 01/21/2024]
Abstract
BACKGROUND The left bundle branch block (LBBB) is associated with ventricular septal mid-wall fibrosis (SMF) in patients with dilated cardiomyopathy (DCM). However, whether LBBB is also associated with SMF in patients with preserved left ventricular ejection fraction (LVEF) remains unclear. METHODS We performed a retrospective study of 210 patients with preserved LVEF (male, n = 116; female, n = 94; mean age, 44 ± 17 years). LBBB was defined as QRS duration ≥140 ms for men or ≥ 130 ms for women, QS or rS in V1-V2, mid-QRS notching or slurring in at least two leads (V1, V2, V5, V6, I, and aVL). SMF determined by late gadolinium-enhancement cardiovascular magnetic resonance was defined as stripe-like or patchy mid-myocardial hyper-enhancement in the interventricular septal segments. RESULTS SMF was detected in 24.8% (52/210) of these patients. The proportion of patients with SMF with LBBB was higher than the proportion of patients with SMF without LBBB (58.3% vs. 20.4%; P < 0.001). In the forward multivariate logistic analysis, LBBB (OR, 4.399; 95% CI, 1.774-10.904; P = 0.001) and age (OR, 1.028; 95% CI, 1.006-1.051; P = 0.011) were independently associated with SMF. The presence of LBBB showed a sensitivity of 27%%, specificity of 94%, positive predictive value of 58%%, and negative predictive value of 80% for the detection of SMF. CONCLUSION LBBB was significantly associated with SMF in hospitalized patients with preserved LVEF. Screening with a resting 12‑lead ECG may help to identify patients who are at a high risk of the presence of SMF.
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Affiliation(s)
- Xiaojie Liu
- Department of Cardiology, Henan University People's Hospital, Henan Provincial People's Hospital, Zhengzhou, China
| | - Muzhang Li
- Department of Cardiology, Central China Fuwai Hospital of Zhengzhou University, Zhengzhou, China
| | - Jiaying Chen
- Department of Cardiology, Central China Fuwai Hospital of Zhengzhou University, Zhengzhou, China
| | - Jintao Wu
- Heart Centre of Henan Provincial People's Hospital, Central China Fuwai Hospital, Central China Fuwai Hospital of Zhengzhou University, Zhengzhou, China.
| | - Leiming Zhang
- Heart Centre of Henan Provincial People's Hospital, Central China Fuwai Hospital, Central China Fuwai Hospital of Zhengzhou University, Zhengzhou, China
| | - Juan Hu
- Heart Centre of Henan Provincial People's Hospital, Central China Fuwai Hospital, Central China Fuwai Hospital of Zhengzhou University, Zhengzhou, China
| | - Feifei Li
- Human Resource Department, The Third Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Xianwei Fan
- Heart Centre of Henan Provincial People's Hospital, Central China Fuwai Hospital, Central China Fuwai Hospital of Zhengzhou University, Zhengzhou, China
| | - Haitao Yang
- Heart Centre of Henan Provincial People's Hospital, Central China Fuwai Hospital, Central China Fuwai Hospital of Zhengzhou University, Zhengzhou, China
| | - Lijie Yan
- Heart Centre of Henan Provincial People's Hospital, Central China Fuwai Hospital, Central China Fuwai Hospital of Zhengzhou University, Zhengzhou, China
| | - Jingjing Liu
- Heart Centre of Henan Provincial People's Hospital, Central China Fuwai Hospital, Central China Fuwai Hospital of Zhengzhou University, Zhengzhou, China
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Mugnai G, Donazzan L, Tomasi L, Piccoli A, Cavedon S, Manfrin M, Bolzan B, Perrone C, Lavio S, Rauhe WG, Oberhollenzer R, Bilato C, Ribichini FL. Electrocardiographic predictors of echocardiographic response in cardiac resynchronization therapy: Update of an old story. J Electrocardiol 2022; 75:36-43. [PMID: 36274327 DOI: 10.1016/j.jelectrocard.2022.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 09/18/2022] [Accepted: 10/01/2022] [Indexed: 01/05/2023]
Abstract
BACKGROUND A better selection of patients with left bundle branch block (LBBB) might increase the response to cardiac resynchronization therapy (CRT). The aim of the study was to investigate the association between the Strauss criteria, absence of S wave in V5-V6, the Selvester score and response to CRT. METHODS AND RESULTS The retrospective analysis included all consecutive patients having undergone implantation of biventricular defibrillators in primary prevention between 2018 and 2020. The final analysis included 236 patients (mean age 69.7 ± 9.9; 77.5% of males). The Strauss criteria were significantly associated with CRT response (p < 0.01) with a sensitivity of 71.3% and specificity of 64.1%. The Strauss criteria along with the absence of S wave in V5 and V6 showed a sensitivity of 56.7%, a specificity of 82.6% and a positive predictive value of 90.5%. The Selvester score was significantly and inversely associated with CRT response (OR 0.818, 95% CI 0.75-0.89; p < 0.001). The multivariable model showed that left ventricular ejection fraction (LVEF) and QRS duration (≥140 ms in males and ≥ 130 ms in females) were independently associated with CRT response (respectively OR 0.92, CI 95% 0.86-0.98, p = 0.01 and OR 3.70, CI 95% 1.12-12.21, p = 0.03). CONCLUSIONS Strauss criteria, especially in association with absence of S wave in V5 and V6, were able to increase specificity and positive predictive value for predicting CRT response. The Selvester score was inversely associated with CRT response. Finally, LVEF and QRS duration were independently associated with echocardiographic response to CRT.
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Affiliation(s)
- Giacomo Mugnai
- Electrophysiology and Cardiac Pacing, Division of Cardiology, Cardio-Thoracic Department, University Hospital of Verona, Verona, Italy.
| | - Luca Donazzan
- Electrophysiology and Cardiac Pacing Unit, San Maurizio Regional Hospital, Bolzano, Italy
| | - Luca Tomasi
- Electrophysiology and Cardiac Pacing, Division of Cardiology, Cardio-Thoracic Department, University Hospital of Verona, Verona, Italy
| | - Anna Piccoli
- Electrophysiology and Cardiac Pacing, Division of Cardiology, Cardio-Thoracic Department, University Hospital of Verona, Verona, Italy
| | - Stefano Cavedon
- Electrophysiology and Cardiac Pacing Unit, Division of Cardiology, West Vicenza General Hospitals, Arzignano (Vicenza), Italy
| | - Massimiliano Manfrin
- Electrophysiology and Cardiac Pacing Unit, San Maurizio Regional Hospital, Bolzano, Italy
| | - Bruna Bolzan
- Electrophysiology and Cardiac Pacing, Division of Cardiology, Cardio-Thoracic Department, University Hospital of Verona, Verona, Italy
| | - Cosimo Perrone
- Electrophysiology and Cardiac Pacing Unit, Division of Cardiology, West Vicenza General Hospitals, Arzignano (Vicenza), Italy
| | | | - Werner Günther Rauhe
- Electrophysiology and Cardiac Pacing Unit, San Maurizio Regional Hospital, Bolzano, Italy
| | - Rainer Oberhollenzer
- Electrophysiology and Cardiac Pacing Unit, San Maurizio Regional Hospital, Bolzano, Italy
| | - Claudio Bilato
- Electrophysiology and Cardiac Pacing Unit, Division of Cardiology, West Vicenza General Hospitals, Arzignano (Vicenza), Italy
| | - Flavio Luciano Ribichini
- Electrophysiology and Cardiac Pacing, Division of Cardiology, Cardio-Thoracic Department, University Hospital of Verona, Verona, Italy
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Gillette K, Gsell MAF, Strocchi M, Grandits T, Neic A, Manninger M, Scherr D, Roney CH, Prassl AJ, Augustin CM, Vigmond EJ, Plank G. A personalized real-time virtual model of whole heart electrophysiology. Front Physiol 2022; 13:907190. [PMID: 36213235 PMCID: PMC9539798 DOI: 10.3389/fphys.2022.907190] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 08/15/2022] [Indexed: 01/12/2023] Open
Abstract
Computer models capable of representing the intrinsic personal electrophysiology (EP) of the heart in silico are termed virtual heart technologies. When anatomy and EP are tailored to individual patients within the model, such technologies are promising clinical and industrial tools. Regardless of their vast potential, few virtual technologies simulating the entire organ-scale EP of all four-chambers of the heart have been reported and widespread clinical use is limited due to high computational costs and difficulty in validation. We thus report on the development of a novel virtual technology representing the electrophysiology of all four-chambers of the heart aiming to overcome these limitations. In our previous work, a model of ventricular EP embedded in a torso was constructed from clinical magnetic resonance image (MRI) data and personalized according to the measured 12 lead electrocardiogram (ECG) of a single subject under normal sinus rhythm. This model is then expanded upon to include whole heart EP and a detailed representation of the His-Purkinje system (HPS). To test the capacities of the personalized virtual heart technology to replicate standard clinical morphological ECG features under such conditions, bundle branch blocks within both the right and the left ventricles under two different conduction velocity settings are modeled alongside sinus rhythm. To ensure clinical viability, model generation was completely automated and simulations were performed using an efficient real-time cardiac EP simulator. Close correspondence between the measured and simulated 12 lead ECG was observed under normal sinus conditions and all simulated bundle branch blocks manifested relevant clinical morphological features.
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Affiliation(s)
- Karli Gillette
- Gottfried Schatz Research Center—Biophysics, Medical University of Graz, Graz, Austria
- BioTechMed-Graz, Graz, Austria
| | - Matthias A. F. Gsell
- Gottfried Schatz Research Center—Biophysics, Medical University of Graz, Graz, Austria
- NAWI Graz, Institute of Mathematics and Scientific Computing, University of Graz, Graz, Austria
| | | | - Thomas Grandits
- Gottfried Schatz Research Center—Biophysics, Medical University of Graz, Graz, Austria
- NAWI Graz, Institute of Mathematics and Scientific Computing, University of Graz, Graz, Austria
| | | | - Martin Manninger
- Division of Cardiology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Daniel Scherr
- Division of Cardiology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | | | - Anton J. Prassl
- Gottfried Schatz Research Center—Biophysics, Medical University of Graz, Graz, Austria
- BioTechMed-Graz, Graz, Austria
| | - Christoph M. Augustin
- Gottfried Schatz Research Center—Biophysics, Medical University of Graz, Graz, Austria
- BioTechMed-Graz, Graz, Austria
| | | | - Gernot Plank
- Gottfried Schatz Research Center—Biophysics, Medical University of Graz, Graz, Austria
- BioTechMed-Graz, Graz, Austria
- *Correspondence: Gernot Plank,
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Melgaard J, van Dam PM, Sommer A, Fruelund P, Nielsen JC, Riahi S, Graff C. Non-invasive estimation of QLV from the standard 12-lead ECG in patients with left bundle branch block. Front Physiol 2022; 13:939240. [PMID: 36213226 PMCID: PMC9532835 DOI: 10.3389/fphys.2022.939240] [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: 05/08/2022] [Accepted: 08/29/2022] [Indexed: 11/13/2022] Open
Abstract
Background: Cardiac resynchronization therapy (CRT) is a treatment for patients with heart failure and electrical dyssynchrony, i.e., left bundle branch block (LBBB) ECG pattern. CRT resynchronizes ventricular contraction with a right ventricle (RV) and a left ventricle (LV) pacemaker lead. Positioning the LV lead in the latest electrically activated region (measured from Q wave onset in the ECG to LV sensing by the left pacemaker electrode [QLV]) is associated with favorable outcome. However, optimal LV lead placement is limited by coronary venous anatomy and the inability to measure QLV non-invasively before implantation. We propose a novel non-invasive method for estimating QLV in sinus-rhythm from the standard 12-lead ECG.Methods: We obtained 12-lead ECG, LV electrograms and LV lead position in a standard LV 17-segment model from procedural recordings from 135 standard CRT recipients. QLV duration was measured post-operatively. Using a generic heart geometry and corresponding forward model for ECG computation, the electrical activation pattern of the heart was fitted to best match the 12-lead ECG in an iterative optimization procedure. This procedure initialized six activation sites associated with the His-Purkinje system. The initial timing of each site was based on the directions of the vectorcardiogram (VCG). Timing and position of the sites were then changed iteratively to improve the match between simulated and measured ECG. Noninvasive estimation of QLV was done by calculating the time difference between Q-onset on the computed ECG and the activation time corresponding to centroidal epicardial activation time of the segment where the LV electrode is positioned. The estimated QLV was compared to the measured QLV. Further, the distance between the actual LV position and the estimated LV position was computed from the generic ventricular model.Results: On average there was no difference between QLV measured from procedural recordings and non-invasive estimation of QLV (ΔQLV=−3.0±22.5 ms, p=0.12). Median distance between actual LV pacing site and the estimated pacing site was 18.6 mm (IQR 17.3 mm).Conclusion: Using the standard 12-lead ECG and a generic heart model it is possible to accurately estimate QLV. This method may potentially be used to support patient selection, optimize implant procedures, and to simulate optimal stimulation parameters prior to pacemaker implantation.
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Affiliation(s)
- Jacob Melgaard
- CardioTech Research Group, Department of Health Science and Technology, Faculty of Medicine, Aalborg University, Aalborg, Denmark
- *Correspondence: Jacob Melgaard,
| | - Peter M. van Dam
- Department of Cardiology, University Medical Center Utrecht, Utrecht, Netherlands
- Peacs BV, Nieuwerbrug Aan Den Rijn, Netherlands
| | - Anders Sommer
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
| | - Patricia Fruelund
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
| | | | - Sam Riahi
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
| | - Claus Graff
- CardioTech Research Group, Department of Health Science and Technology, Faculty of Medicine, Aalborg University, Aalborg, Denmark
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Marcu DTM, Adam CA, Dorobanțu DM, Șalaru DL, Sascău RA, Balasanian MO, Macovei L, Arsenescu-Georgescu C, Stătescu C. Beta-Blocker-Related Atrioventricular Conduction Disorders—A Single Tertiary Referral Center Experience. Medicina (B Aires) 2022; 58:medicina58020320. [PMID: 35208643 PMCID: PMC8877089 DOI: 10.3390/medicina58020320] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 02/15/2022] [Accepted: 02/17/2022] [Indexed: 12/24/2022] Open
Abstract
Background and Objectives: Drug-related bradyarrhythmia is a well-documented major adverse event among beta-blocker users and a potential cause for hospitalization or additional interventions. Whether beta-blocker use is associated with specific bradyarrhythmia presentations, and how this relates to other predisposing factors, is not well known. We aim to evaluate the association between beta-blocker use and the type of atrioventricular (AV) conduction disorder in patients with symptomatic bradycardia. Materials and Methods: We conducted a retrospective cohort study on 596 patients with a primary diagnosis of symptomatic bradyarrhythmia admitted to a single tertiary referral center. Of the cases analyzed, 253 patients were on beta-blocker treatment at presentation and 343 had no bradycardic treatment. We analyzed demographics, clinical and paraclinical parameters in relation to the identified AV conduction disorder. A multivariate regression analysis was performed to explore factors associated with beta-blocker use. Results: Of the 596 patients (mean age 73.9 ± 8.8 years, 49.2% male), 261 (43.8%) had a third-degree AV block, 92 (15.4%) had a second-degree AV block, 128 (21.5%) had slow atrial fibrillation, 93 (15.6%) had sick sinus syndrome and 21 (3.5%) had sinus bradycardia/sinus pauses. Beta-blocker use was associated with the female gender (p < 0.001), emergency admission (p < 0.001), dilated cardiomyopathy (p = 0.003), the lower left ventricular ejection fraction (p = 0.02), mitral stenosis (p = 0.009), chronic kidney disease (p = 0.02), higher potassium levels (p = 0.04) and QRS duration > 120 ms (p = 0.02). Slow atrial fibrillation (OR = 4.2, p < 0.001), sick sinus syndrome (OR = 2.8, p = 0.001) and sinus bradycardia/pauses (OR = 32.9, p < 0.001) were more likely to be associated with beta-blocker use compared to the most common presentation (third-degree AV block), after adjusting for other patient characteristics. Conclusions: Beta-blocker use is more likely to be associated with slow atrial fibrillation, sick sinus syndrome and sinus bradycardia/pauses, compared to a second- or third-degree AV block, after adjusting for other patient factors such as gender, admission type, ECG, comorbidities, cardiac function and lab testing.
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Affiliation(s)
- Dragoș Traian Marius Marcu
- Department of Internal Medicine, University of Medicine and Pharmacy “Grigore T. Popa” Iași, 700115 Iasi, Romania; (D.T.M.M.); (D.L.Ș.); (R.A.S.); (M.O.B.); (L.M.); (C.A.-G.); (C.S.)
| | - Cristina Andreea Adam
- Institute of Cardiovascular Diseases “Prof. Dr. George I. M. Georgescu” Iași, 700115 Iasi, Romania
- Correspondence:
| | - Dan-Mihai Dorobanțu
- Children’s Health and Exercise Research Centre (CHERC), University of Exeter, Exeter EX1 2LU, UK;
- Congenital Heart Unit, Bristol Royal Hospital for Children and Heart Institute, Bristol BS2 8BJ, UK
| | - Delia Lidia Șalaru
- Department of Internal Medicine, University of Medicine and Pharmacy “Grigore T. Popa” Iași, 700115 Iasi, Romania; (D.T.M.M.); (D.L.Ș.); (R.A.S.); (M.O.B.); (L.M.); (C.A.-G.); (C.S.)
- Institute of Cardiovascular Diseases “Prof. Dr. George I. M. Georgescu” Iași, 700115 Iasi, Romania
| | - Radu Andy Sascău
- Department of Internal Medicine, University of Medicine and Pharmacy “Grigore T. Popa” Iași, 700115 Iasi, Romania; (D.T.M.M.); (D.L.Ș.); (R.A.S.); (M.O.B.); (L.M.); (C.A.-G.); (C.S.)
- Institute of Cardiovascular Diseases “Prof. Dr. George I. M. Georgescu” Iași, 700115 Iasi, Romania
| | - Mircea Ovanez Balasanian
- Department of Internal Medicine, University of Medicine and Pharmacy “Grigore T. Popa” Iași, 700115 Iasi, Romania; (D.T.M.M.); (D.L.Ș.); (R.A.S.); (M.O.B.); (L.M.); (C.A.-G.); (C.S.)
- Institute of Cardiovascular Diseases “Prof. Dr. George I. M. Georgescu” Iași, 700115 Iasi, Romania
| | - Liviu Macovei
- Department of Internal Medicine, University of Medicine and Pharmacy “Grigore T. Popa” Iași, 700115 Iasi, Romania; (D.T.M.M.); (D.L.Ș.); (R.A.S.); (M.O.B.); (L.M.); (C.A.-G.); (C.S.)
- Institute of Cardiovascular Diseases “Prof. Dr. George I. M. Georgescu” Iași, 700115 Iasi, Romania
| | - Cătălina Arsenescu-Georgescu
- Department of Internal Medicine, University of Medicine and Pharmacy “Grigore T. Popa” Iași, 700115 Iasi, Romania; (D.T.M.M.); (D.L.Ș.); (R.A.S.); (M.O.B.); (L.M.); (C.A.-G.); (C.S.)
| | - Cristian Stătescu
- Department of Internal Medicine, University of Medicine and Pharmacy “Grigore T. Popa” Iași, 700115 Iasi, Romania; (D.T.M.M.); (D.L.Ș.); (R.A.S.); (M.O.B.); (L.M.); (C.A.-G.); (C.S.)
- Institute of Cardiovascular Diseases “Prof. Dr. George I. M. Georgescu” Iași, 700115 Iasi, Romania
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7
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Boonstra MJ, Brooks DH, Loh P, van Dam PM. CineECG: A novel method to image the average activation sequence in the heart from the 12-lead ECG. Comput Biol Med 2022; 141:105128. [PMID: 34973587 DOI: 10.1016/j.compbiomed.2021.105128] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 12/08/2021] [Accepted: 12/08/2021] [Indexed: 11/03/2022]
Abstract
The standard 12-lead electrocardiogram (ECG) is a diagnostic tool to asses cardiac electrical activity. The vectorcardiogram is a related tool that represents that activity as the direction of a vector. In this work we investigate CineECG, a new 12-lead ECG based analysis method designed to directly estimate the average cardiac anatomical location of activation over time. We describe CineECG calculation and a novel comparison parameter, the average isochrone position (AIP). In a model study, fourteen different activation sequences were simulated and corresponding 12-lead ECGs were computed. The CineECG was compared to AIP in terms of location and direction. In addition, 67-lead body surface potential maps from ten patients were used to study the sensitivity of CineECG to electrode mispositioning and anatomical model selection. Epicardial activation maps from four patients were used for further evaluation. The average distance between CineECG and AIP across the fourteen sequences was 23.7 ± 2.4 mm, with significantly better agreement in the terminal (27.3 ± 5.7 mm) versus the initial QRS segment (34.2 ± 6.1 mm). Up to four cm variation in electrode positioning produced an average distance of 6.5 ± 4.5 mm between CineECG trajectories, while substituting a generic heart/torso model for a patient-specific one produced an average difference of 6.1 ± 4.8 mm. Dominant epicardial activation map features were recovered. Qualitatively, CineECG captured significant features of activation sequences and was robust to electrode misplacement. CineECG provides a realistic representation of the average cardiac activation in normal and diseased hearts. In particular, the terminal segment of the CineECG might be useful to detect pathology.
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Affiliation(s)
- Machteld J Boonstra
- Department of Cardiology, Division Heart & Lungs, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Dana H Brooks
- Electrical and Computer Engineering, Northeastern University, Boston, MA, 02115, USA
| | - Peter Loh
- Department of Cardiology, Division Heart & Lungs, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Peter M van Dam
- Department of Cardiology, Division Heart & Lungs, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands; ECG Excellence BV, Nieuwerbrug aan den Rijn, the Netherlands.
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Boonstra MJ, Hilderink BN, Locati ET, Asselbergs FW, Loh P, van Dam PM. Novel CineECG enables anatomical 3D localization and classification of bundle branch blocks. Europace 2021; 23:i80-i87. [PMID: 33751077 DOI: 10.1093/europace/euaa396] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Accepted: 12/03/2020] [Indexed: 11/13/2022] Open
Abstract
AIMS Ventricular conduction disorders can induce arrhythmias and impair cardiac function. Bundle branch blocks (BBBs) are diagnosed by 12-lead electrocardiogram (ECG), but discrimination between BBBs and normal tracings can be challenging. CineECG computes the temporo-spatial trajectory of activation waveforms in a 3D heart model from 12-lead ECGs. Recently, in Brugada patients, CineECG has localized the terminal components of ventricular depolarization to right ventricle outflow tract (RVOT), coincident with arrhythmogenic substrate localization detected by epicardial electro-anatomical maps. This abnormality was not found in normal or right BBB (RBBB) patients. This study aimed at exploring whether CineECG can improve the discrimination between left BBB (LBBB)/RBBB, and incomplete RBBB (iRBBB). METHODS AND RESULTS We utilized 500 12-lead ECGs from the online Physionet-XL-PTB-Diagnostic ECG Database with a certified ECG diagnosis. The mean temporo-spatial isochrone trajectory was calculated and projected into the anatomical 3D heart model. We established five CineECG classes: 'Normal', 'iRBBB', 'RBBB', 'LBBB', and 'Undetermined', to which each tracing was allocated. We determined the accuracy of CineECG classification with the gold standard diagnosis. A total of 391 ECGs were analysed (9 ECGs were excluded for noise) and 240/266 were correctly classified as 'normal', 14/17 as 'iRBBB', 55/55 as 'RBBB', 51/51 as 'LBBB', and 31 as 'undetermined'. The terminal mean temporal spatial isochrone contained most information about the BBB localization. CONCLUSION CineECG provided the anatomical localization of different BBBs and accurately differentiated between normal, LBBB and RBBB, and iRBBB. CineECG may aid clinical diagnostic work-up, potentially contributing to the difficult discrimination between normal, iRBBB, and Brugada patients.
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Affiliation(s)
- Machteld J Boonstra
- Division Heart & Lungs, Department of Cardiology, University Medical Center Utrecht, Utrecht 3508 GA, Heidelberglaan 100, Utrecht, The Netherlands
| | - Bashar N Hilderink
- Division Heart & Lungs, Department of Cardiology, University Medical Center Utrecht, Utrecht 3508 GA, Heidelberglaan 100, Utrecht, The Netherlands
| | - Emanuela T Locati
- Department of Arrhythmology and Electrophysiology, IRCCS Policlinico San Donato, Milano, Italy
| | - Folkert W Asselbergs
- Division Heart & Lungs, Department of Cardiology, University Medical Center Utrecht, Utrecht 3508 GA, Heidelberglaan 100, Utrecht, The Netherlands.,Netherlands Heart Institute, Utrecht, The Netherlands.,Institute of Cardiovascular Science, Institute of Health Informatics, Faculty of Population Health Sciences, University College London, London, UK
| | - Peter Loh
- Division Heart & Lungs, Department of Cardiology, University Medical Center Utrecht, Utrecht 3508 GA, Heidelberglaan 100, Utrecht, The Netherlands
| | - Peter M van Dam
- Division Heart & Lungs, Department of Cardiology, University Medical Center Utrecht, Utrecht 3508 GA, Heidelberglaan 100, Utrecht, The Netherlands.,ECG Excellence BV, Nieuwerbrug aan den Rijn, The Netherlands
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9
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Aimo A, Valleggi A, Barison A, Salerni S, Emdin M, Aquaro GD. Morphologies and prognostic significance of left ventricular volume/time curves with cardiac magnetic resonance in patients with non-ischaemic heart failure and left bundle branch block. Int J Cardiovasc Imaging 2021; 37:2245-2255. [PMID: 33635416 PMCID: PMC8286944 DOI: 10.1007/s10554-021-02194-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2020] [Accepted: 02/13/2021] [Indexed: 12/15/2022]
Abstract
Patients with non-ischaemic systolic heart failure (HF) and left bundle branch block (LBBB) can display a wide or narrow pattern (WP/NP) of the systolic phase of the left ventricular (LV) volume/time (V/t) curve in cardiac magnetic resonance (CMR). The clinical and prognostic significance of these patterns is unknown. Consecutive patients with non-ischaemic HF, LV ejection fraction < 50% and LBBB underwent 1.5 T CMR. Maximal dyssynchrony time (time between the earliest and latest end-systolic peaks), systolic dyssynchrony index (standard deviation of times to peak volume change), and contractility index (maximum rate of change of pressure-normalized stress) were calculated. The endpoint was a composite of cardiovascular death, HF hospitalization, and appropriate defibrillator shock. NP was found in 29 and WP in 72 patients. WP patients had higher volumes and NT-proBNP, and lower LVEF. WP patients had a longer maximal dyssynchrony time (absolute duration: 192 ± 80 vs. 143 ± 65 ms, p < 0.001; % of RR interval: 25 ± 11% vs. 8 ± 4%, p < 0.001), a higher systolic dyssynchrony index (13 ± 4 vs. 7 ± 3%, p < 0.001), and a lower contractility index (2.6 ± 1.2 vs 3.2 ± 1.7, p < 0.05). WP patients had a shorter survival free from the composite endpoint regardless of age, NT-proBNP or LVEF. Nonetheless, WP patients responded more often to cardiac resynchronization therapy (CRT) than those with NP (24/28 [86%] vs. 1/11 [9%] responders, respectively; p < 0.001). In patients with non-ischaemic systolic HF and LBBB, the WP of V/t curves identifies a subgroup of patients with greater LV dyssynchrony and worse outcome, but better response to CRT.
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Affiliation(s)
- Alberto Aimo
- Scuola Superiore Sant'Anna, Piazza Martiri della Libertà 33, 56124, Pisa, Italy.
- Fondazione Toscana Gabriele Monasterio, Piazza Martiri della Libertà 33, 56124, Pisa, Italy.
| | - Alessandro Valleggi
- Fondazione Toscana Gabriele Monasterio, Piazza Martiri della Libertà 33, 56124, Pisa, Italy
| | - Andrea Barison
- Scuola Superiore Sant'Anna, Piazza Martiri della Libertà 33, 56124, Pisa, Italy
- Fondazione Toscana Gabriele Monasterio, Piazza Martiri della Libertà 33, 56124, Pisa, Italy
| | | | - Michele Emdin
- Scuola Superiore Sant'Anna, Piazza Martiri della Libertà 33, 56124, Pisa, Italy
- Fondazione Toscana Gabriele Monasterio, Piazza Martiri della Libertà 33, 56124, Pisa, Italy
| | - Giovanni Donato Aquaro
- Fondazione Toscana Gabriele Monasterio, Piazza Martiri della Libertà 33, 56124, Pisa, Italy
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10
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Kuznetsov VA, Malishevskii LM, Todosiychuk VV, Soldatova AM. [Association of left bundle branch block definitions with response to cardiac resynchronisation therapy in patients with congestive heart failure]. ACTA ACUST UNITED AC 2020; 60:78-85. [PMID: 33155944 DOI: 10.18087/cardio.2020.7.n785] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Revised: 05/26/2020] [Accepted: 06/02/2020] [Indexed: 11/18/2022]
Abstract
Aim To compare diagnostic significance of different criteria for complete left bundle branch block (cLBBB) in prediction of reverse left ventricular (LV) remodeling associated with cardiac resynchronization therapy (CRT).Materials and methods This study included 93 patients (men, 81.7 %; mean age at the time of implantation, 56.6±9.3 years). Achievement of a maximum decrease in LV end-systolic volume (ESV) was recorded during the entire follow-up period for evaluation of LV reversibility by CRT. Based on the dynamics of LV ESV, patients were divided into two groups, non-responders (n=27) and responders (n=66). cLBBB was determined by 9 criteria (ESC 2006 and 2013, AHA 2009, Strauss, and MIRACLE, CARE-HF, MADIT-CRT, REVERSE, and RAFT used in large multicenter studies).Results Incidence of cLBBB was significantly higher in the group of responders as demonstrated by the AHA (p=0.001), ESC 2013 (p=0.014), Strauss (p=0.002), MADIT-CRT (p=0.014), REVERSE (p=0.013), and RAFT (p<0.001) criteria. The highest specificity was shown for the AHA and RAFT (92.6 %) criteria, and the highest sensitivity and overall accuracy were shown for the Strauss (80.3 % and 72.04 %, respectively) criterium. The criteria proposed in actual clinical guidelines (AHA and ESC 2013) demonstrated a strong consistency in detecting cLBBB (κ=0.818, 95 % CI, 0.7-0.936; p<0.001). However, the Strauss and ESC 2006 / AHA / ESC 2013 showed the least consistency in identifying cLBBB. For the criteria described in large multicenter studies, consistency in detecting cLBBB was minimal in most cases. However, criteria with moderate or strong consistency were used in the studies, which results have substantiated the use of cLBBB as a selection criterium (MADIT-CRT, REVERSE, and RAFT).Conclusion The reversibility of LV remodeling associated with CRT was different in patients with cLBBB determined by different criteria. All actual cLBBB criteria (AHA, ESC 2013, and Strauss) were significantly more frequently observed in the responder group. Nevertheless, these criteria differed in their sensitivity and specificity. A number of large multicenter studies have used criteria with minimal consistency in detecting cLBBB, which should be taken into account in interpreting results of these studies.
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Affiliation(s)
- V A Kuznetsov
- Tomsk National Research Medical Center of the Russian Academy of Sciences, Tyumen Cardiology Research Center, Tomsk, Russia
| | - L M Malishevskii
- Tomsk National Research Medical Center of the Russian Academy of Sciences, Tyumen Cardiology Research Center, Tomsk, Russia
| | - V V Todosiychuk
- Tomsk National Research Medical Center of the Russian Academy of Sciences, Tyumen Cardiology Research Center, Tomsk, Russia
| | - A M Soldatova
- Tomsk National Research Medical Center of the Russian Academy of Sciences, Tyumen Cardiology Research Center, Tomsk, Russia
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11
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Yang T, Gregg RE, Babaeizadeh S. Detection of strict left bundle branch block by neural network and a method to test detection consistency. Physiol Meas 2020; 41:025005. [PMID: 31962304 DOI: 10.1088/1361-6579/ab6e55] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVE To develop an automatic algorithm to detect strict left bundle branch block (LBBB) on electrocardiograms (ECG) and propose a procedure to test the consistency of neural network detections. APPROACH The database for the classification of strict LBBB was provided by Telemetric and Holter ECG Warehouse. It contained 10 s ECGs taken from the MADIT-CRT clinical trial. The database was divided into a training dataset (N = 300, strict LBBB = 174, non-strict LBBB = 126) and a test dataset (N = 302, strict LBBB = 156, non-strict LBBB = 146). LBBB-related features were extracted by Philips DXL™ algorithm, selected by a random forest classifier, and fed into a 5-layer neural network (NN) for the classification of strict LBBB on the training dataset. The performance of NN on the test dataset was compared to two random forest classifiers, an algorithm applying strict LBBB criteria, a wavelet-based approach, and a support-vector-machine approach. The consistency of NN's detection was tested on 549 2 min recordings of the PTB diagnostic ECG database. LBBB annotations are not required to measure consistency. MAIN RESULTS The performance of NN on the test dataset were sensitivity = 91. 7%, specificity = 85.6% and accuracy = 88.7% (PPV = 87.2%, NPV = 90.6%). The consistency score of strict-LBBB and non-strict-LBBB detection was 0.9341 and 0.9973 respectively. CONCLUSION NN achieved the highest specificity, accuracy, and PPV. Using random forest for feature selection and NN for classification increased interpretability and reduced computational cost. The consistency test showed that NN achieved high consistency scores in the detection of strict LBBB. SIGNIFICANCE This work proposed an approach for selecting features and training NN for the detection of strict LBBB as well as a consistency test for black-box algorithms.
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Affiliation(s)
- Ting Yang
- Advanced Algorithm Research Center, Philips Healthcare, Andover, MA, United States of America
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12
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Left Bundle Branch Block Chest Pain Conundrum. Case Rep Cardiol 2020; 2020:2724981. [PMID: 32148969 PMCID: PMC7053445 DOI: 10.1155/2020/2724981] [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: 09/15/2019] [Revised: 01/21/2020] [Accepted: 01/30/2020] [Indexed: 11/17/2022] Open
Abstract
Left bundle branch block is a pattern of altered ventricular depolarization and subsequently affects repolarization. These obscure patterns can affect the traditional ST segment shift criteria for the electrocardiographic detection of coronary insufficiency syndromes. Previously, patients with coronary ischemic pain and LBBB judged to be "new" (not previously documented) were considered to have ST elevation myocardial infarction (STEMI) warranting acute thrombolytic therapy. Current STEMI management favors emergent invasive angiography; however, recent data suggests the prevalence of coronary obstructive pathology may be as low as 50%. The application of more specific, less-sensitive Sgarbossa electrocardiographic criteria may reduce angiographic assessment in an otherwise high-risk population unlikely to tolerate further myocardial injury. We present a case that may facilitate a more nuanced EKG-based approach to distinguish those who may benefit from acute invasive angiography while reducing the frequency of unnecessary angiographic evaluation.
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13
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Abstract
Cardiac resynchronization therapy constitutes a cornerstone in advanced heart failure treatment, when there is evidence of dyssynchrony, especially by electrocardiography. However, it is plagued both by persistently high (~30%) rates of nonresponse and by deterioration of right ventricular function, owing to iatrogenic dyssynchrony in the context of persistent apical pacing to ensure delivery of biventricular pacing. Left ventricular pacing has long been considered an alternative to standard biventricular pacing and can be achieved as easily as inserting a single pacing electrode in the coronary sinus. Although monoventricular left ventricular pacing has been proven to yield comparable results with the standard biventricular modality, it is the advent of preferential left ventricular pacing, combining both the powerful resynchronization potential of multipolar coronary sinus and right-sided electrodes acting in concert and the ability to preserve intrinsic, physiological right ventricular activation. In this review, we aim to present the underlying principles and modes for delivering left ventricular pacing, as well as to highlight advantages of preferential over monoventricular configuration. Finally, current clinical evidence, following implementation of automated algorithms, regarding performance of left ventricular as compared with biventricular pacing will be discussed. It is expected that the field of preferential left ventricular pacing will grow significantly over the following years, and its combination with other advanced pacing modalities may promote clinical status and prognosis of patients with advanced dyssynchronous heart failure.
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14
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Kusumoto FM, Schoenfeld MH, Barrett C, Edgerton JR, Ellenbogen KA, Gold MR, Goldschlager NF, Hamilton RM, Joglar JA, Kim RJ, Lee R, Marine JE, McLeod CJ, Oken KR, Patton KK, Pellegrini CN, Selzman KA, Thompson A, Varosy PD. 2018 ACC/AHA/HRS guideline on the evaluation and management of patients with bradycardia and cardiac conduction delay. Heart Rhythm 2019; 16:e128-e226. [DOI: 10.1016/j.hrthm.2018.10.037] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Indexed: 12/13/2022]
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15
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Kusumoto FM, Schoenfeld MH, Barrett C, Edgerton JR, Ellenbogen KA, Gold MR, Goldschlager NF, Hamilton RM, Joglar JA, Kim RJ, Lee R, Marine JE, McLeod CJ, Oken KR, Patton KK, Pellegrini CN, Selzman KA, Thompson A, Varosy PD. 2018 ACC/AHA/HRS Guideline on the Evaluation and Management of Patients With Bradycardia and Cardiac Conduction Delay: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. Circulation 2019; 140:e382-e482. [DOI: 10.1161/cir.0000000000000628] [Citation(s) in RCA: 97] [Impact Index Per Article: 19.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
| | | | | | | | - Kenneth A. Ellenbogen
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information
- ACC/AHA Representative
| | - Michael R. Gold
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information
- HRS Representative
| | | | | | - José A. Joglar
- ACC/AHA Task Force on Clinical Practice Guidelines Liaison
| | | | | | | | | | | | | | - Cara N. Pellegrini
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information
- HRS Representative
- Dr. Pellegrini contributed to this article in her personal capacity. The views expressed are her own and do not necessarily represent the views of the US Department of Veterans Affairs or the US government
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16
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Sillanmäki S, Lipponen JA, Tarvainen MP, Laitinen T, Hedman M, Hedman A, Kivelä A, Hämäläinen H, Laitinen T. Relationships between electrical and mechanical dyssynchrony in patients with left bundle branch block and healthy controls. J Nucl Cardiol 2019; 26:1228-1239. [PMID: 29423906 DOI: 10.1007/s12350-018-1204-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Accepted: 01/15/2018] [Indexed: 10/18/2022]
Abstract
BACKGROUND Abnormal electrical activation may cause dyssynchronous left ventricular (LV) contraction. In this study, we characterized and analyzed electrical and mechanical dyssynchrony in patient with left bundle branch block (LBBB) and healthy controls. METHODS Myocardial perfusion imaging (MPI) data from 994 patients were analyzed. Forty-three patient fulfilled criteria for LBBB and 24 for controls. Electrical activation was characterized with vector electrocardiography (VECG) and LV function including mechanical dyssynchrony with ECG-gated MPI phase analysis. RESULTS QRS duration (QRSd; r = 0.69, P < .001) and a few other VECG parameters correlated significantly with phase bandwidth (phaseBW) representing mechanical dyssynchrony. End-diastolic volume (EDV; r = 0.59, P < .001), ejection fraction and end-systolic volume correlated also with phaseBW. QRSd (β = 0.47, P < .001) and EDV (β = 0.36, P = .001) were independently associated with phaseBW explaining 55% of its variation. Sixty percent of patients with LBBB had significant mechanical dyssynchrony. Those patients had wider QRSd (159 vs 147 ms, P = .013) and larger EDV (144 vs 94 mL, P = .008) than those with synchronous LV contraction. Cut-off values for mechanical dyssynchrony seen in patients with LBBB were QRSd ≥ 165 ms and EDV ≥ 109 mL. CONCLUSIONS Despite obvious conduction abnormality, LBBB is not always accompanied by mechanical dyssynchrony. QRSd and EDV explained 55% of variation seen in phaseBW. These two parameters were statistically different between LBBB cases with and without mechanical dyssynchrony.
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Affiliation(s)
- Saara Sillanmäki
- Department of Clinical Physiology and Nuclear Medicine, Kuopio University Hospital, Puijonlaaksontie 2, 70210, Kuopio, Finland.
- Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland.
| | - Jukka A Lipponen
- Department of Applied Physics, University of Eastern Finland, Kuopio, Finland
| | - Mika P Tarvainen
- Department of Clinical Physiology and Nuclear Medicine, Kuopio University Hospital, Puijonlaaksontie 2, 70210, Kuopio, Finland
- Department of Applied Physics, University of Eastern Finland, Kuopio, Finland
| | - Tiina Laitinen
- Department of Clinical Physiology and Nuclear Medicine, Kuopio University Hospital, Puijonlaaksontie 2, 70210, Kuopio, Finland
| | - Marja Hedman
- Department of Clinical Radiology, Kuopio University Hospital, Kuopio, Finland
| | - Antti Hedman
- Heart Center, Kuopio University Hospital, Kuopio, Finland
| | - Antti Kivelä
- Heart Center, Kuopio University Hospital, Kuopio, Finland
| | - Hanna Hämäläinen
- Department of Clinical Physiology and Nuclear Medicine, Kuopio University Hospital, Puijonlaaksontie 2, 70210, Kuopio, Finland
| | - Tomi Laitinen
- Department of Clinical Physiology and Nuclear Medicine, Kuopio University Hospital, Puijonlaaksontie 2, 70210, Kuopio, Finland
- Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
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17
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Kusumoto FM, Schoenfeld MH, Barrett C, Edgerton JR, Ellenbogen KA, Gold MR, Goldschlager NF, Hamilton RM, Joglar JA, Kim RJ, Lee R, Marine JE, McLeod CJ, Oken KR, Patton KK, Pellegrini CN, Selzman KA, Thompson A, Varosy PD. 2018 ACC/AHA/HRS Guideline on the Evaluation and Management of Patients With Bradycardia and Cardiac Conduction Delay. J Am Coll Cardiol 2019; 74:e51-e156. [DOI: 10.1016/j.jacc.2018.10.044] [Citation(s) in RCA: 151] [Impact Index Per Article: 30.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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18
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Pérez-Riera AR, Barbosa-Barros R, Daminello-Raimundo R, de Abreu LC, de Almeida MC, Rankinen J, Baeub Soler F, Nikus K. Re-evaluating the electro-vectorcardiographic criteria for left bundle branch block. Ann Noninvasive Electrocardiol 2019; 24:e12644. [PMID: 30938470 DOI: 10.1111/anec.12644] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Revised: 01/03/2019] [Accepted: 01/23/2019] [Indexed: 11/26/2022] Open
Abstract
The criteria for left bundle branch block have gained growing interest in the last few years. In this overview, we discuss diagnostic and prognostic aspects of different criteria. It was already shown that stricter criteria, including longer QRS duration and slurring/notching of the QRS, better identify responders to cardiac resynchronization therapy. We also include aspects of ST/T concordance and discordance and vectorcardiography, which could further improve in the fine-tuning of the left bundle branch criteria.
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Affiliation(s)
| | - Raimundo Barbosa-Barros
- Coronary Center, de Messejana Hospital Dr. Carlos Alberto Studart Gomes, Fortaleza, Ceará, Brazil
| | | | - Luiz Carlos de Abreu
- Study Design and Scientific Writing Laboratory, ABC Faculty of Medicine, Santo André, São Paulo, Brazil
| | - Marcos Célio de Almeida
- IInstitute of Biology-Genetics and Morphology, University of Brasília, Brasília, Federal District, Brazil
| | - Jani Rankinen
- Heart Center, Tampere University Hospital and Faculty of Medicine and Life Sciences, University of Tampere, Tampere, Finland
| | | | - Kjell Nikus
- Heart Center, Tampere University Hospital and Faculty of Medicine and Life Sciences, University of Tampere, Tampere, Finland
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19
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Hadjis A, AlTurki A, Proietti R, Montemezzo M, Bernier M, Joza J, Hadjis T, Essebag V. Predicting response to cardiac resynchronization therapy: Use of strict left bundle branch block criteria. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2019; 42:431-438. [DOI: 10.1111/pace.13638] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/02/2018] [Revised: 01/25/2019] [Accepted: 02/08/2019] [Indexed: 10/27/2022]
Affiliation(s)
- Alexios Hadjis
- Department of CardiologyMcGill University Health Centre Montreal Quebec Canada
| | - Ahmed AlTurki
- Department of CardiologyMcGill University Health Centre Montreal Quebec Canada
| | - Riccardo Proietti
- Department of Cardiac, Thoracic and Vascular SciencesUniversity of Padua Padua Italy
| | - Mauricio Montemezzo
- Department of CardiologyMcGill University Health Centre Montreal Quebec Canada
| | - Martin Bernier
- Department of CardiologyMcGill University Health Centre Montreal Quebec Canada
| | - Jacqueline Joza
- Department of CardiologyMcGill University Health Centre Montreal Quebec Canada
| | - Tomy Hadjis
- Department of CardiologyMcGill University Health Centre Montreal Quebec Canada
- Department of CardiologyHôpital Sacré‐Coeur de Montréal Montreal Quebec Canada
| | - Vidal Essebag
- Department of CardiologyMcGill University Health Centre Montreal Quebec Canada
- Department of CardiologyHôpital Sacré‐Coeur de Montréal Montreal Quebec Canada
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20
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Iiya M, Shimizu M, Fujii H, Suzuki M, Nishizaki M. True complete left bundle branch block reveals dyssynchrony evaluated by semiconductor single-photon emission computed tomography. J Arrhythm 2019; 35:70-78. [PMID: 30805046 PMCID: PMC6373645 DOI: 10.1002/joa3.12148] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Revised: 11/02/2018] [Accepted: 11/19/2018] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Conventional complete left bundle branch block (CLBBB) criteria sometimes result in a false-positive diagnosis that does not represent dyssynchrony. Recently, true CLBBB criteria have been proposed to detect responders to cardiac resynchronization therapy (CRT), although their correlation with severity of dyssynchrony or natural prognosis is unclear. METHODS Ninety-four consecutive patients (74 ± 9 years, 63 men) with conventional CLBBB during sinus rhythm underwent semiconductor SPECT. They were divided into two groups: patients with true CLBBB and others. True CLBBB was characterized by the mid-QRS notching/slurring and wide QRS duration (male, ≥140 milliseconds; female, ≥130 milliseconds). Multivariate analysis was performed to detect left ventricular dyssynchrony (LVD), defined as bandwidth ≥145° and/or phase standard deviation (SD) ≥43°. Primary endpoints (hospitalization for heart failure or cardiac death) were evaluated. RESULTS True CLBBB had wider bandwidth (145 ± 83° vs 110 ± 64°, P = 0.024) and higher phase SD (48 ± 26° vs 35 ± 19°, P = 0.007). Ejection fraction (EF), end-diastolic volume (EDV), summed rest score (SRS), and the presence of ischemic heart disease (IHD) showed no differences between groups (P = 0.401, 0.591, 0.165, and 0.212, respectively). Multivariate analysis revealed that true CLBBB, EF, and EDV were significant predictors of LVD (odds ratio, 12.6, 0.90, 1.03; P = 0.003, 0.002, 0.022, respectively). At 3-year follow-up (median 667 days), primary endpoints were comparable in both groups (log-rank, P = 0.92). CONCLUSIONS Patients with true CLBBB had more severe dyssynchrony on single-photon emission computed tomography than patients with nontrue CLBBB. On the other hand, the two groups showed no differences in EF, EDV, the presence of IHD, hospitalization for heart failure, and cardiac death.
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Affiliation(s)
- Munehiro Iiya
- Department of CardiologyYokohama Minami Kyosai HospitalYokohamaJapan
| | - Masato Shimizu
- Department of CardiologyYokohama Minami Kyosai HospitalYokohamaJapan
| | - Hiroyuki Fujii
- Department of CardiologyYokohama Minami Kyosai HospitalYokohamaJapan
| | - Makoto Suzuki
- Department of CardiologyYokohama Minami Kyosai HospitalYokohamaJapan
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Poulidakis E, Aggeli C, Sideris S, Sfendouraki E, Koutagiar I, Katsaros A, Giannoulis E, Koukos M, Margioula E, Lagoudakou S, Gatzoulis K, Dilaveris P, Kallikazaros I, Couloheri S, Stefanadis C, Tousoulis D. Echocardiography for prediction of 6-month and late response to cardiac resynchronization therapy: implementation of stress echocardiography and comparative assessment along with widely used dyssynchrony indices. Int J Cardiovasc Imaging 2019; 35:285-294. [PMID: 30623352 DOI: 10.1007/s10554-018-01520-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2018] [Accepted: 12/24/2018] [Indexed: 12/28/2022]
Abstract
Non-response cardiac resynchronization therapy (CRT) remains an issue, despite the refinement of selection criteria. The purpose of this study was to investigate the role of stress echocardiography along with dyssynchrony parameters for identification of CRT responders or late responders. 106 symptomatic heart failure patients were examined before, 6 months and 2-4 years after CRT implementation. Inotropic contractile reserve (ICR) and inferolateral (IL) wall viability were studied by stress echocardiography. Dyssynchrony was assessed by: (1) Septal to posterior wall motion delay (SPWMD) by m-mode. (2) Septal to lateral wall delay (SLD) by TDI. (3) Interventricular mechanical delay (IVMD) by pulsed wave Doppler for (4) difference in time to peak circumferential strain (TmaxCS) by speckle tracking. (5) Apical rocking (ApR) and septal flash (SF) by visual assessment. At 6 months there were 54 responders, with 12 additional late responders. TmaxCS had the greatest predictive value with an area under curve (AUC) of 0.835, followed by the presence of both ICR and viability of IL wall (AUC 0.799), m-mode (AUC = 0.775) and presence of either ApR or SF (AUC = 0.772). Predictive ability of ApR and of ICR is augmented if late responders are also included. Performance of dyssynchrony parameters is enhanced, in patients with both ICR and IL wall viability. Stress echocardiography and dyssynchrony parameters are simple and reliable predictors of 6-month and late CRT response. A stepwise approach with an initial assessment of ICR and viability and, if positive, further dyssynchrony analysis, could assist decision making.
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Affiliation(s)
- Emmanouil Poulidakis
- Department of Cardiology, Evagelismos General Hospital of Athens, 45 Ipsilandou st, 10676, Athens, Greece.
- Hôpital Européen Georges-Pompidou, 20 rue Leblanc, 75015, Paris, France.
| | - Constantina Aggeli
- First Cardiology Clinic, Hippokration Hospital, University of Athens, 114 Vas. Sofias Ave, 11528, Athens, Greece
| | - Skevos Sideris
- Cardiology Department, Hippokration Hospital, 114 Vas. Sofias Ave, 11528, Athens, Greece
| | - Eliza Sfendouraki
- Cardiology Department, Hippokration Hospital, 114 Vas. Sofias Ave, 11528, Athens, Greece
| | - Iosif Koutagiar
- First Cardiology Clinic, Hippokration Hospital, University of Athens, 114 Vas. Sofias Ave, 11528, Athens, Greece
| | - Andreas Katsaros
- Cardiosurgery Department, Hippokration Hospital, 114 Vas. Sofias Ave, 11528, Athens, Greece
| | - Evangelos Giannoulis
- Department of Cardiology, Evagelismos General Hospital of Athens, 45 Ipsilandou st, 10676, Athens, Greece
| | - Markos Koukos
- Department of Cardiology, Evagelismos General Hospital of Athens, 45 Ipsilandou st, 10676, Athens, Greece
| | - Eleni Margioula
- Department of Cardiology, Evagelismos General Hospital of Athens, 45 Ipsilandou st, 10676, Athens, Greece
| | - Stavroula Lagoudakou
- First Cardiology Clinic, Hippokration Hospital, University of Athens, 114 Vas. Sofias Ave, 11528, Athens, Greece
| | - Kostas Gatzoulis
- First Cardiology Clinic, Hippokration Hospital, University of Athens, 114 Vas. Sofias Ave, 11528, Athens, Greece
| | - Polychronis Dilaveris
- First Cardiology Clinic, Hippokration Hospital, University of Athens, 114 Vas. Sofias Ave, 11528, Athens, Greece
| | - Ioannis Kallikazaros
- Department of Cardiology, Evagelismos General Hospital of Athens, 45 Ipsilandou st, 10676, Athens, Greece
| | - Stavroula Couloheri
- Department of Biological Chemistry, Medical School, University of Athens, 75 M. Asias st, 115 27, Athens, Greece
| | - Christodoulos Stefanadis
- First Cardiology Clinic, Hippokration Hospital, University of Athens, 114 Vas. Sofias Ave, 11528, Athens, Greece
| | - Dimitrios Tousoulis
- First Cardiology Clinic, Hippokration Hospital, University of Athens, 114 Vas. Sofias Ave, 11528, Athens, Greece
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Morrison TM, Pathmanathan P, Adwan M, Margerrison E. Advancing Regulatory Science With Computational Modeling for Medical Devices at the FDA's Office of Science and Engineering Laboratories. Front Med (Lausanne) 2018; 5:241. [PMID: 30356350 PMCID: PMC6167449 DOI: 10.3389/fmed.2018.00241] [Citation(s) in RCA: 62] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Accepted: 08/08/2018] [Indexed: 12/29/2022] Open
Abstract
Protecting and promoting public health is the mission of the U.S. Food and Drug Administration (FDA). FDA's Center for Devices and Radiological Health (CDRH), which regulates medical devices marketed in the U.S., envisions itself as the world's leader in medical device innovation and regulatory science-the development of new methods, standards, and approaches to assess the safety, efficacy, quality, and performance of medical devices. Traditionally, bench testing, animal studies, and clinical trials have been the main sources of evidence for getting medical devices on the market in the U.S. In recent years, however, computational modeling has become an increasingly powerful tool for evaluating medical devices, complementing bench, animal and clinical methods. Moreover, computational modeling methods are increasingly being used within software platforms, serving as clinical decision support tools, and are being embedded in medical devices. Because of its reach and huge potential, computational modeling has been identified as a priority by CDRH, and indeed by FDA's leadership. Therefore, the Office of Science and Engineering Laboratories (OSEL)-the research arm of CDRH-has committed significant resources to transforming computational modeling from a valuable scientific tool to a valuable regulatory tool, and developing mechanisms to rely more on digital evidence in place of other evidence. This article introduces the role of computational modeling for medical devices, describes OSEL's ongoing research, and overviews how evidence from computational modeling (i.e., digital evidence) has been used in regulatory submissions by industry to CDRH in recent years. It concludes by discussing the potential future role for computational modeling and digital evidence in medical devices.
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Affiliation(s)
- Tina M. Morrison
- Office of Science and Engineering Laboratories, Center for Devices and Radiological Health, U.S. Food and Drug Administration, Silver Spring, MD, United States
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Gray RA, Pathmanathan P. Patient-Specific Cardiovascular Computational Modeling: Diversity of Personalization and Challenges. J Cardiovasc Transl Res 2018; 11:80-88. [PMID: 29512059 PMCID: PMC5908828 DOI: 10.1007/s12265-018-9792-2] [Citation(s) in RCA: 73] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Accepted: 02/02/2018] [Indexed: 02/07/2023]
Abstract
Patient-specific computer models have been developed representing a variety of aspects of the cardiovascular system spanning the disciplines of electrophysiology, electromechanics, solid mechanics, and fluid dynamics. These physiological mechanistic models predict macroscopic phenomena such as electrical impulse propagation and contraction throughout the entire heart as well as flow and pressure dynamics occurring in the ventricular chambers, aorta, and coronary arteries during each heartbeat. Such models have been used to study a variety of clinical scenarios including aortic aneurysms, coronary stenosis, cardiac valvular disease, left ventricular assist devices, cardiac resynchronization therapy, ablation therapy, and risk stratification. After decades of research, these models are beginning to be incorporated into clinical practice directly via marketed devices and indirectly by improving our understanding of the underlying mechanisms of health and disease within a clinical context.
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Affiliation(s)
- Richard A Gray
- Division of Biomedical Physics, Office of Science and Engineering Laboratories, Center for Devices and Radiological Health, Food and Drug Administration, Silver Spring, MD, 20993, USA.
- , Silver Spring, USA.
| | - Pras Pathmanathan
- Division of Biomedical Physics, Office of Science and Engineering Laboratories, Center for Devices and Radiological Health, Food and Drug Administration, Silver Spring, MD, 20993, USA
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Grigoratos C, Liga R, Bennati E, Barison A, Todiere G, Aquaro GD, Dell'Omodarme M, Emdin M, Masci PG. Magnetic Resonance Imaging Correlates of Left Bundle Branch Disease in Patients With Nonischemic Cardiomyopathy. Am J Cardiol 2018; 121:370-376. [PMID: 29191565 DOI: 10.1016/j.amjcard.2017.10.024] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Revised: 10/13/2017] [Accepted: 10/13/2017] [Indexed: 11/16/2022]
Abstract
The pathologic correlates of intraventricular conduction delays in patients with nonischemic cardiomyopathy (NIC) have been scarcely investigated. We assessed left ventricular (LV) structural, functional, and tissue abnormalities associated with intraventricular conduction left bundle disease (LBD), including left anterior hemiblock or complete left bundle branch block, in a cohort of patients with NIC submitted to cardiovascular magnetic resonance. Twelve-lead electrocardiogram and cardiovascular magnetic resonance were performed in 196 consecutive patients with NIC. The presence and extent of myocardial fibrosis was evaluated with late gadolinium enhancement (LGE) technique. Compared with normal intraventricular conduction patients, those with LBD were older (66 vs 59 years, p = 0.001), had greater LV volumes (p = 0.035 for end-diastolic and p = 0.009 for end-systolic volume) and mass (p = 0.034), and showed lower LV ejection fraction (33% vs 40%, p = 0.008). LGE was observed more commonly in LBD than in normal intraventricular conduction patients and was more often located in the ventricular septum (p < 0.001). On multivariate analysis, septal LGE was independently associated with a higher likelihood of LBD (odds ratio 6.1, 95% confidence interval 2.9 to 12.7, p < 0.001), even after correction for LV volumes, mass, and ejection fraction. In conclusion, in NIC, the presence of LBD is associated with worse LV remodeling and dysfunction than normal intraventricular conduction. Septal fibrosis yielded a 6-fold greater likelihood of LBD, independently of the degree of LV dilatation and systolic dysfunction.
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Affiliation(s)
- Chrysanthos Grigoratos
- Fondazione G. Monasterio CNR-Regione Toscana, Pisa, Italy; Institute of Life Sciences, Scuola Superiore Sant'Anna, Pisa, Italy.
| | - Riccardo Liga
- Cardiac, Thoracic and Vascular Department, University of Pisa, Pisa, Italy
| | - Elena Bennati
- Department of Cardiovascular Diseases, University of Siena, Siena, Italy
| | - Andrea Barison
- Fondazione G. Monasterio CNR-Regione Toscana, Pisa, Italy; Institute of Life Sciences, Scuola Superiore Sant'Anna, Pisa, Italy
| | | | | | | | - Michele Emdin
- Fondazione G. Monasterio CNR-Regione Toscana, Pisa, Italy; Institute of Life Sciences, Scuola Superiore Sant'Anna, Pisa, Italy
| | - Pier Giorgio Masci
- Centre for cardiac MRI/Department of Cardiology, University Hospital of Lausanne, Lausanne, Switzerland
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25
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Bertaglia E, Migliore F, Baritussio A, De Simone A, Reggiani A, Pecora D, D'Onofrio A, Rapacciuolo A, Savarese G, Pierantozzi A, Marenna B, Ruffa F, Campari M, Malacrida M, Stabile G. Stricter criteria for left bundle branch block diagnosis do not improve response to CRT. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2017; 40:850-856. [PMID: 28543265 DOI: 10.1111/pace.13104] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/09/2017] [Revised: 04/20/2017] [Accepted: 04/28/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND Cardiac resynchronization therapy (CRT) has proved to be effective in patients with heart failure and left bundle branch block (LBBB). Recently, new electrocardiography criteria have been proposed for the diagnosis of LBBB. These criteria are stricter than the current American Heart Association (AHA) criteria. We assessed the rate of echocardiographic response to CRT in patients with traditional LBBB versus patients who met the new criteria (strict LBBB). METHODS Consecutive patients undergoing CRT were enrolled in the CRT MORE registry. Patients with no-LBBB QRS morphology according to AHA criteria, atrial fibrillation, right bundle branch block, and right ventricular pacing were excluded. Strict LBBB was defined as: QRS ≥ 140 ms for men and ≥130 ms for women, QS or rS in V1-V2, mid-QRS notching or slurring in ≥2 contiguous leads. Patients showing a relative decrease of ≥15% in left ventricular end-systolic volume (LVESV) at 12 months were defined as responders. RESULTS Among 335 patients with LBBB, 131 (39%) had strict LBBB. Patients with and without strict LBBB showed comparable baseline characteristics, except for QRS duration (166 ± 20 ms vs 152 ± 25 ms, P < 0.001). On 12-month evaluation, 205 patients (61%) were responders; 85 of 131 (65%) had strict LBBB and 120 of 204 (59%) had traditional LBBB (P = 0.267). On multivariate analysis, a history of atrial fibrillation, larger LVESV, and the presence of mid-QRS notching in ≥1 lead (odds ratio 2.099; 95% confidence interval 1.061-4.152, P = 0.033) were independently associated with echocardiographic response. CONCLUSION Stricter definition of LBBB did not improve response to CRT in comparison to the current AHA definition.
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Affiliation(s)
- Emanuele Bertaglia
- Department of Cardiac, Thoracic, and Vascular Sciences, University of Padova, Padova, Italy
| | - Federico Migliore
- Department of Cardiac, Thoracic, and Vascular Sciences, University of Padova, Padova, Italy
| | - Anna Baritussio
- Department of Cardiac, Thoracic, and Vascular Sciences, University of Padova, Padova, Italy
| | | | | | | | | | - Antonio Rapacciuolo
- Department of Advanced Biomedical Sciences, Federico II University, Naples, Italy
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Surkova E, Badano LP, Bellu R, Aruta P, Sambugaro F, Romeo G, Migliore F, Muraru D. Left bundle branch block: from cardiac mechanics to clinical and diagnostic challenges. Europace 2017; 19:1251-1271. [DOI: 10.1093/europace/eux061] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Accepted: 02/14/2017] [Indexed: 12/15/2022] Open
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Mazza A, Bendini MG, De Cristofaro R, Lovecchio M, Valsecchi S, Leggio M, Boriani G. Prevalence and clinical significance of left bundle branch block according to classical or strict definition criteria in permanent pacemaker patients. Clin Cardiol 2017; 40:377-382. [PMID: 28294356 DOI: 10.1002/clc.22673] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Revised: 12/07/2016] [Accepted: 12/20/2016] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Previous studies have shown that the presence of left bundle branch block (LBBB) is associated with an increased risk of cardiac mortality and heart failure (HF). Recently, new criteria to define strict LBBB have been proposed: QRS duration ≥140 ms for men and ≥130 ms for women, along with mid-QRS notching or slurring in ≥2 contiguous leads. HYPOTHESIS We assessed the prevalence and prognostic significance of LBBB according to classical (QRS duration ≥120ms) and strict criteria in permanent pacemaker patients. METHODS We retrospectively enrolled 723 consecutive patients who had undergone single- or dual-chamber pacemaker implantation at the study center from July 2002 to December 2014. Patients with a left ventricular ejection fraction ≤35% or a prior diagnosis of HF were excluded. RESULTS LBBB was reported in 54 (7%) patients, and strict-LBBB in 15 (2%) patients. During a median follow-up of 48 months (range, 18-92 months), 147 (20%) patients reached the combined endpoint of death or HF hospitalization. Patients with LBBB and those with strict-LBBB displayed significantly higher rates of death or HF hospitalization (log-rank test, all P < 0.0001). In particular, strict-LBBB was associated with the worst outcome. The presence of LBBB according to classical definition criteria (hazard ratio [HR] = 1.98, confidence interval [CI]: 1.23-3.19, P = 0.005) and to strict criteria (HR = 2.20; CI: 1.04-4.65; P = 0.039) were both confirmed as independent predictors of death or HF hospitalization after adjustment for relevant clinical covariates. CONCLUSIONS Among patients who had undergone standard pacemaker implantation, the prevalence of LBBB was 7% according to classical definition criteria and 2% according to strict criteria. The presence of LBBB, and particularly of strict-LBBB, at the baseline predicted a poor outcome in terms of death or HF hospitalization.
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Affiliation(s)
- Andrea Mazza
- Cardiology Department, Santa Maria della Stella Hospital, Orvieto, Italy
| | | | | | | | | | - Massimo Leggio
- Salus Infirmorum Clinic, San Filippo Neri Hospital, Rome, Italy
| | - Giuseppe Boriani
- Cardiology Division, Department of Diagnostics, Clinical and Public Health Medicine, University of Modena and Reggio Emilia, Modena Hospital, Modena, Italy
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Left bundle-branch block contraction patterns identified from radial-strain analysis predicts outcomes following cardiac resynchronization therapy. Int J Cardiovasc Imaging 2017; 33:869-877. [PMID: 28150083 DOI: 10.1007/s10554-017-1083-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2016] [Accepted: 01/24/2017] [Indexed: 10/20/2022]
Abstract
A left bundle-branch block (LBBB) contraction pattern identified from longitudinal-strain analysis predicts outcomes following cardiac resynchronization therapy (CRT). We investigated the use of an LBBB-contraction pattern identified from radial- or circumferential-strain analysis in the prediction of CRT benefits. Eighty CRT candidates were prospectively enrolled. Before CRT implantation, speckle-tracking analyses in three deformation directions were performed to determine whether an LBBB-contraction pattern was present. The study endpoints were reverse remodeling at 6 months, and adverse outcomes including death or heart failure hospitalization. At 6 months, 49 (61%) patients had reverse remodeling. An LBBB-contraction pattern identified from the radial strain in the mid-ventricular short-axis view or longitudinal strain in the four-chamber view provided excellent true-positive (86%) and false-negative (8%) rates for predicting reverse remodeling. During a median follow-up of 30 months, 31 patients (39%) had adverse outcomes. Absence of an LBBB-contraction pattern in radial (hazard ratio 3.74; 95% confidence interval 1.83-7.62) or longitudinal strain (hazard ratio 3.49; 95% confidence interval 1.71-7.13) was significantly associated with an increased risk of adverse outcomes. Adding the LBBB-pattern assessment by radial-(model χ2 from 8.2 to 18.5, p = 0.005), or longitudinal-strain analysis (model χ2 from 8.2 to 16.9, p = 0.011) to a risk model significantly improved the model, including QRS duration and ischemic etiology. In conclusion, an LBBB-contraction pattern identified from radial-strain analysis in the mid-ventricular short-axis view predicted reverse remodeling and outcome following CRT, similarly to the longitudinal-strain analysis.
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Xia X, Ruwald AC, Ruwald MH, Ugoeke N, Szepietowska B, Kutyifa V, Aktas MK, Thomsen PEB, Zareba W, Moss AJ, Couderc JP. Validation of an automatic diagnosis of strict left bundle branch block criteria using 12-lead electrocardiograms. Ann Noninvasive Electrocardiol 2016; 22. [PMID: 27572179 DOI: 10.1111/anec.12398] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
AIMS Strict left bundle branch block (LBBB) criteria were recently proposed to identify LBBB patients to benefit most from cardiac resynchronization therapy (CRT). The aim of our study was to automate identification of strict LBBB in order to facilitate its broader application. METHODS We developed a series of algorithms to automatically detect and measure parameters required for strict LBBB criteria and proposed a definition of QRS notch detection. The algorithms were developed using training (n = 20) and validation (n = 592) sets consisting of signal-averaged 12-lead ECGs (1,000 Hz sampling) recorded from 612 LBBB patients from Multicenter Automatic Defibrillator Implantation Trial-CRT. Four trained clinicians independently performed adjudication on 148 different ECGs for comparing automatic and manually adjudicated results, in addition to 13 ECGs for evaluation of intraobserver variability and 32 ECGs for interobserver variability. We assessed the performance of the automated algorithms using manually adjudicated ECGs as references. RESULTS Overall sensitivity and specificity for detecting strict LBBB were 95% and 86%, respectively. The mean absolute deviation (MAD) of QRS duration and notch/slur locations for the automated method versus the manual method was below 1 ms, and MAD values were lower than 2 ms for interobserver and intraobserver variability. Sensitivity and specificity for detecting notch and slur locations were 87% and 96% for notches and 78% and 90% for slurs using the automatic method. In addition 95% and 93% agreements for notches and 90% and 88% agreements for slurs were reached for intra- and interobserver. CONCLUSION The proposed algorithms automatically measure QRS features for the diagnosis of strict LBBB. Our study shows good performance in reference to manual results.
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Affiliation(s)
- Xiaojuan Xia
- Heart Research Follow-Up Program, University of Rochester, Rochester, NY, USA
| | - Anne-Christine Ruwald
- Heart Research Follow-Up Program, University of Rochester, Rochester, NY, USA.,Department of Cardiology, Gentofte University Hospital, Copenhagen, Denmark
| | - Martin H Ruwald
- Heart Research Follow-Up Program, University of Rochester, Rochester, NY, USA.,Department of Cardiology, Bispebjerg Hospital, Copenhagen, Denmark
| | - Nene Ugoeke
- Heart Research Follow-Up Program, University of Rochester, Rochester, NY, USA
| | | | - Valentina Kutyifa
- Heart Research Follow-Up Program, University of Rochester, Rochester, NY, USA
| | - Mehmet K Aktas
- Heart Research Follow-Up Program, University of Rochester, Rochester, NY, USA
| | | | - Wojciech Zareba
- Heart Research Follow-Up Program, University of Rochester, Rochester, NY, USA
| | - Arthur J Moss
- Heart Research Follow-Up Program, University of Rochester, Rochester, NY, USA
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Migliore F, Baritussio A, Stabile G, Reggiani A, D’Onofrio A, Palmisano P, Caico SI, De Simone A, Marini M, Pecora D, Padeletti L, Botto GL, Malacrida M, Bertaglia E. Prevalence of true left bundle branch block in current practice of cardiac resynchronization therapy implantation. J Cardiovasc Med (Hagerstown) 2016; 17:462-8. [DOI: 10.2459/jcm.0000000000000297] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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31
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Lee YYL, Reidler P, Jelinek H, Lee YS, Zhou Y, Hambly BD, McCabe J, Matthews S, Ke H, Assareh H, McLachlan CS. Electrocardiogram derived QRS duration associations with elevated central aortic systolic pressure (CASP) in a rural Australian population. Clin Hypertens 2016; 22:6. [PMID: 26893940 PMCID: PMC4754924 DOI: 10.1186/s40885-016-0039-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2015] [Accepted: 01/08/2016] [Indexed: 01/08/2023] Open
Abstract
Background Prolonged electrocardiogram QRS durations are often present in hypertensive patients. Small increases in QRS duration serve as independent risk factors for both increased cardiovascular and all-cause mortality. Aortic stiffness is associated with increases in central aortic systolic blood pressure (CASP). However CASP and ECG QRS duration interactions have not been established in rural community populations. Our aims are to determine if QRS duration > 100 msec is associated with an elevated CASP measure in an Australian rural population. Methods A retrospective cross sectional population was obtained from the CSU Diabetes Screening Research Initiative data base where 68 participants had both central aortic pressure recorded and ECG derived QRS duration. Central aortic pressure was determined by directly recording radial arterial tonometry and brachial cuff pressure (HealthStats, Singapore). Resting 12-lead electrocardiograms were obtained from each subject using a Welch Allyn PC-Based ECG system. Results The population had a mean CASP of 137.8 mmHg, higher than previously reported in other population studies. In 8/68 subjects with a prolonged cardiac QRS duration >120 msec, CASP ranged from 129 mmHg – 182 mmHg. When subgroup analysis was stratified on the basis QRS duration <100 msec and ≥100 msec significant differences (p = 0.036) were observed for mean CASP, 130.6 mmHg ± 15.6 (SD) versus 140.6 mmHg ± 16.8 (SD), respectively. Conclusions Our results suggest that an arbitrary CASP reading greater than a value 140 mmHg raises suspicion of a prolonged QRS duration. QRS durations ≥100 msec in an aging rural population are associated with higher CASP measures. Our results also suggest in aging Australian rural populations CASP is likely to be elevated, possibly due to age related aortic stiffening.
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Affiliation(s)
- Yvonne Yin Leng Lee
- Rural Clinical School, Faculty of Medicine, University of New South Wales, Room 327, Samuels Building, Sydney, NSW 2052 Australia
| | - Paul Reidler
- School of Health Sciences, Charles Stuart University, Albury, Australia
| | - Herbert Jelinek
- School of Health Sciences, Charles Stuart University, Albury, Australia
| | - Yung Seng Lee
- Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore ; Singapore Institute for Clinical Sciences, ASTAR, Singapore, Singapore
| | - Yuling Zhou
- Rural Clinical School, Faculty of Medicine, University of New South Wales, Room 327, Samuels Building, Sydney, NSW 2052 Australia
| | - Brett D Hambly
- Discipline of Pathology, Sydney Medical School, University of Sydney, Sydney, Australia
| | - Joel McCabe
- Rural Clinical School, Faculty of Medicine, University of New South Wales, Room 327, Samuels Building, Sydney, NSW 2052 Australia
| | - Slade Matthews
- Discipline of Pharmacology, Sydney Medical School, University of Sydney, Sydney, Australia
| | - Honghong Ke
- Department of Cardiology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Hassan Assareh
- Rural Clinical School, Faculty of Medicine, University of New South Wales, Room 327, Samuels Building, Sydney, NSW 2052 Australia
| | - Craig S McLachlan
- Rural Clinical School, Faculty of Medicine, University of New South Wales, Room 327, Samuels Building, Sydney, NSW 2052 Australia
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Leeters IPM, Davis A, Zusterzeel R, Atwater B, Risum N, Søgaard P, Klem I, Nijveldt R, Wagner GS, Gorgels APM, Kisslo J. Left ventricular regional contraction abnormalities by echocardiographic speckle tracking in combined right bundle branch with left anterior fascicular block compared to left bundle branch block. J Electrocardiol 2016; 49:353-61. [PMID: 26931516 DOI: 10.1016/j.jelectrocard.2016.02.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND In contrast to LBBB patients less is known about patients with RBBB+LAFB regarding LV contractile abnormalities and the potential role of CRT. This study investigated whether patients with RBBB+LAFB morphology have echocardiographic mechanical strain abnormalities between the inferior and anterior LV walls, similar to abnormalities between septal and lateral walls in LBBB. METHODS AND RESULTS Ten healthy volunteers with no-BBB, 28 LBBB and 28 RBBB+LAFB heart failure patients were included in this retrospective study. Two-dimensional regional-strains were obtained by speckle-tracking. Scar was assessed by CMR. Response on echo was defined as normal, classical, borderline or other pattern. The number of classical patterns in LBBB was significantly higher than in RBBB+LAFB and no-BBB groups (p<0.001 for both). Contrary, the RBBB+LAFB group showed a significantly higher number of borderline patterns compared to other groups (LBBB: p=0.042, no-block: p=0.012). In addition, RBBB+LAFB patients had more scar than LBBB patients (9.9% vs 3.4%, p=0.041), and the average amount of scar in each wall was also higher in RBBB+LAFB (<5% in LBBB and <16% in RBBB+LAFB). CONCLUSIONS Patients with RBBB+LAFB on ECG and clinical HF demonstrate echocardiographic wall motion abnormalities between inferior and anterior LV walls, similar to abnormalities found between septal and lateral LV walls in patients with LBBB and HF. Fewer patients with RBBB+LAFB showed a classical pattern of opposing wall motion compared to LBBB. Factors that might alter strain patterns in RBBB+LAFB, including the detailed presence or absence of LV scar and coexisting block of the central fascicle, should be assessed in future studies.
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Affiliation(s)
- Irene P M Leeters
- Department of Cardiology, Maastricht University Medical Center, Maastricht, The Netherlands.
| | - Ashlee Davis
- Department of Cardiology, Duke University Medical Center, Durham, NC, USA
| | | | - Brett Atwater
- Department of Cardiology, Duke University Medical Center, Durham, NC, USA
| | - Niels Risum
- Department of Cardiology, Copenhagen University Hospital, Copenhagen, Denmark
| | - Peter Søgaard
- Heart Centre and Clinical Institute, Aalborg University Hospital, Aalborg, Denmark
| | - Igor Klem
- Department of Cardiology, Duke University Medical Center, Durham, NC, USA
| | - Robin Nijveldt
- Department of Cardiology, VU University Medical Center, Amsterdam, The Netherlands
| | - Galen S Wagner
- Department of Cardiology, Duke University Medical Center, Durham, NC, USA
| | - Anton P M Gorgels
- Department of Cardiology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Joseph Kisslo
- Department of Cardiology, Duke University Medical Center, Durham, NC, USA
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Galeotti L, van Dam PM, Johannesen L, Vicente J, Strauss DG. Computer simulations to investigate the causes of T-wave notching. J Electrocardiol 2015; 48:927-32. [DOI: 10.1016/j.jelectrocard.2015.08.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2015] [Indexed: 11/30/2022]
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Gomez JF, Cardona K, Trenor B. Lessons learned from multi-scale modeling of the failing heart. J Mol Cell Cardiol 2015; 89:146-59. [PMID: 26476237 DOI: 10.1016/j.yjmcc.2015.10.016] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2015] [Revised: 10/07/2015] [Accepted: 10/14/2015] [Indexed: 12/26/2022]
Abstract
Heart failure constitutes a major public health problem worldwide. Affected patients experience a number of changes in the electrical function of the heart that predispose to potentially lethal cardiac arrhythmias. Due to the multitude of electrophysiological changes that may occur during heart failure, the scientific literature is complex and sometimes ambiguous, perhaps because these findings are highly dependent on the etiology, the stage of heart failure, and the experimental model used to study these changes. Nevertheless, a number of common features of failing hearts have been documented. Prolongation of the action potential (AP) involving ion channel remodeling and alterations in calcium handling have been established as the hallmark characteristics of myocytes isolated from failing hearts. Intercellular uncoupling and fibrosis are identified as major arrhythmogenic factors. Multi-scale computational simulations are a powerful tool that complements experimental and clinical research. The development of biophysically detailed computer models of single myocytes and cardiac tissues has contributed greatly to our understanding of processes underlying excitation and repolarization in the heart. The electrical, structural, and metabolic remodeling that arises in cardiac tissues during heart failure has been addressed from different computational perspectives to further understand the arrhythmogenic substrate. This review summarizes the contributions from computational modeling and simulation to predict the underlying mechanisms of heart failure phenotypes and their implications for arrhythmogenesis, ranging from the cellular level to whole-heart simulations. The main aspects of heart failure are presented in several related sections. An overview of the main electrophysiological and structural changes that have been observed experimentally in failing hearts is followed by the description and discussion of the simulation work in this field at the cellular level, and then in 2D and 3D cardiac structures. The implications for arrhythmogenesis in heart failure are also discussed including therapeutic measures, such as drug effects and cardiac resynchronization therapy. Finally, the future challenges in heart failure modeling and simulation will be discussed.
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Affiliation(s)
- Juan F Gomez
- Instituto de Investigación Interuniversitario en Bioingeniería y Tecnología Orientada, al Ser Humano (I3BH), Universitat Politècnica de València, Camino de Vera s/n, 46022 Valencia, Spain.
| | - Karen Cardona
- Instituto de Investigación Interuniversitario en Bioingeniería y Tecnología Orientada, al Ser Humano (I3BH), Universitat Politècnica de València, Camino de Vera s/n, 46022 Valencia, Spain.
| | - Beatriz Trenor
- Instituto de Investigación Interuniversitario en Bioingeniería y Tecnología Orientada, al Ser Humano (I3BH), Universitat Politècnica de València, Camino de Vera s/n, 46022 Valencia, Spain.
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Almer J, Zusterzeel R, Strauss DG, Trägårdh E, Maynard C, Wagner GS, Engblom H. Prevalence of manual Strauss LBBB criteria in patients diagnosed with the automated Glasgow LBBB criteria. J Electrocardiol 2015; 48:558-64. [DOI: 10.1016/j.jelectrocard.2015.01.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2014] [Indexed: 01/23/2023]
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Influence of QRS infarct score and QRS duration prior to transcatheter aortic valve replacement on follow-up left ventricular end systolic volume in patients with new persistent left bundle branch block. J Electrocardiol 2015; 48:637-42. [PMID: 25959263 DOI: 10.1016/j.jelectrocard.2015.04.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2015] [Indexed: 11/24/2022]
Abstract
BACKGROUND New-onset left bundle branch block (LBBB) is a known complication during Transcatheter Aortic Valve Replacement (TAVR). This study evaluated the influence of pre-TAVR cardiac conditions on left ventricular functions in patients with new persistent LBBB post-TAVR. METHODS Only 11 patients qualified for this study because of the strict inclusion criteria. Pre-TAVR electrocardiograms were evaluated for Selvester QRS infarct score and QRS duration, and left ventricular end-systolic volume (LVESV) was used as outcome variable. RESULTS There was a trend towards a positive correlation between QRS score and LVESV of r=0.59 (p=0.058), while there was no relationship between QRS duration and LVESV (r=-0.18 [p=0.59]). CONCLUSION This study showed that patients with new LBBB and higher pre-TAVR QRS infarct score may have worse post-TAVR left ventricular function, however, pre-TAVR QRS duration has no such predictive value. Because of the small sample size these results should be interpreted with caution and assessed in a larger study population.
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Scully CG, Forrest S, Galeotti L, Schwartz SB, Strauss DG. Advancing Regulatory Science to Bring Novel Medical Devices for Use in Emergency Care to Market: The Role of the Food and Drug Administration. Ann Emerg Med 2015; 65:400-3. [DOI: 10.1016/j.annemergmed.2014.07.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2014] [Revised: 06/23/2014] [Accepted: 07/07/2014] [Indexed: 11/15/2022]
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van Dam PM, Proniewska K, Maugenest AM, van Mieghem NM, Maan AC, de Jaegere PPT, Bruining N. Electrocardiographic imaging-based recognition of possible induced bundle branch blocks during transcatheter aortic valve implantations. Europace 2015; 16:750-7. [PMID: 24798965 DOI: 10.1093/europace/euu071] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
AIMS Conventional electrocardiogram (ECG)-based diagnosis of left bundle branch block (LBBB) in patients with left ventricular hypertrophy (LVH) is ambiguous. Left ventricular hypertrophy is often seen in patients with severe aortic stenosis in which a transcatheter aortic valve implantation (TAVI) frequently results in a LBBB due to the mechanical interaction of the artificial valve and the conduction system. In this feasibility study, we propose and evaluate the sensitivity of a new electrocardiographic imaging tool; the cardiac isochrone positioning system (CIPS), visualizing the cardiac activation to detect interventricular conduction patterns pre- and post-TAVI. METHODS AND RESULTS The CIPS translates standard 12-lead ECG into ventricular isochrones, representing the activation sequence. It requires a patient-specific model integrating heart, lungs, and other thoracic structures derived from multi-slice computed tomography. The fastest route-based algorithm was used to estimate the activation isochrones and the results were compared with standard ECG analysis. In 10 patients the CIPS was used to analyse 20 ECGs, 10 pre- and 10 post-TAVI. In 11 cases the CIPS results were in agreement with the ECG-based diagnosis. In two cases there was partial agreement and in seven cases there was disagreement. In four of these cases, the clinical history of the patients favoured interpretation as assessed by CIPS, for the remaining three, it is unknown which method correctly classified the activation. CONCLUSION This feasibility study applying the CIPS shows promising results to classify conduction disorders originating from the left anterior or posterior ventricular wall, or the septum. The visualization of the activation isochrones as well as ventricular model-derived features might support TAVI procedures and the therapy selection afterwards.
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Affiliation(s)
- Peter M van Dam
- Donders Institute for Brain, Cognition and Behavior, Radboud University Medical Center, Geert Groote plein21, 6525 EZ Nijmegen, The Netherlands
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van Deursen CJ, Vernooy K, Dudink E, Bergfeldt L, Crijns HJ, Prinzen FW, Wecke L. Vectorcardiographic QRS area as a novel predictor of response to cardiac resynchronization therapy. J Electrocardiol 2015; 48:45-52. [DOI: 10.1016/j.jelectrocard.2014.10.003] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2014] [Indexed: 12/17/2022]
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van der Graaf AWM, Bhagirath P, van Driel VJHM, Ramanna H, de Hooge J, de Groot NMS, Götte MJW. Computing volume potentials for noninvasive imaging of cardiac excitation. Ann Noninvasive Electrocardiol 2014; 20:132-9. [PMID: 25041476 DOI: 10.1111/anec.12183] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND In noninvasive imaging of cardiac excitation, the use of body surface potentials (BSP) rather than body volume potentials (BVP) has been favored due to enhanced computational efficiency and reduced modeling effort. Nowadays, increased computational power and the availability of open source software enable the calculation of BVP for clinical purposes. In order to illustrate the possible advantages of this approach, the explanatory power of BVP is investigated using a rectangular tank filled with an electrolytic conductor and a patient specific three dimensional model. METHODS MRI images of the tank and of a patient were obtained in three orthogonal directions using a turbo spin echo MRI sequence. MRI images were segmented in three dimensional using custom written software. Gmsh software was used for mesh generation. BVP were computed using a transfer matrix and FEniCS software. RESULTS The solution for 240,000 nodes, corresponding to a resolution of 5 mm throughout the thorax volume, was computed in 3 minutes. The tank experiment revealed that an increased electrode surface renders the position of the 4 V equipotential plane insensitive to mesh cell size and reduces simulated deviations. In the patient-specific model, the impact of assigning a different conductivity to lung tissue on the distribution of volume potentials could be visualized. CONCLUSION Generation of high quality volume meshes and computation of BVP with a resolution of 5 mm is feasible using generally available software and hardware. Estimation of BVP may lead to an improved understanding of the genesis of BSP and sources of local inaccuracies.
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Meijs LPB, Galeotti L, Pueyo EP, Romero D, Jennings RB, Ringborn M, Warren SG, Wagner GS, Strauss DG. An electrocardiographic sign of ischemic preconditioning. Am J Physiol Heart Circ Physiol 2014; 307:H80-7. [PMID: 24778173 PMCID: PMC4080176 DOI: 10.1152/ajpheart.00419.2013] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2013] [Accepted: 04/21/2014] [Indexed: 11/22/2022]
Abstract
Ischemic preconditioning is a form of intrinsic cardioprotection where an episode of sublethal ischemia protects against subsequent episodes of ischemia. Identifying a clinical biomarker of preconditioning could have important clinical implications, and prior work has focused on the electrocardiographic ST segment. However, the electrophysiology biomarker of preconditioning is increased action potential duration (APD) shortening with subsequent ischemic episodes, and APD shortening should primarily alter the T wave, not the ST segment. We translated findings from simulations to canine to patient models of preconditioning to test the hypothesis that the combination of increased [delta (Δ)] T wave amplitude with decreased ST segment elevation characterizes preconditioning. In simulations, decreased APD caused increased T wave amplitude with minimal ST segment elevation. In contrast, decreased action potential amplitude increased ST segment elevation significantly. In a canine model of preconditioning (9 mongrel dogs undergoing 4 ischemia-reperfusion episodes), ST segment amplitude increased more than T wave amplitude during the first ischemic episode [ΔT/ΔST slope = 0.81, 95% confidence interval (CI) 0.46-1.15]; however, during subsequent ischemic episodes the T wave increased significantly more than the ST segment (ΔT/ΔST slope = 2.43, CI 2.07-2.80) (P < 0.001 for interaction of occlusions 2 vs. 1). A similar result was observed in patients (9 patients undergoing 2 consecutive prolonged occlusions during elective percutaneous coronary intervention), with an increase in slope of ΔT/ΔST of 0.13 (CI -0.15 to 0.42) in the first occlusion to 1.02 (CI 0.31-1.73) in the second occlusion (P = 0.02). This integrated analysis of the T wave and ST segment goes beyond the standard approach to only analyze ST elevation, and detects cellular electrophysiology changes of preconditioning.
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Affiliation(s)
- Loek P B Meijs
- Department of Cardiology, Catharina Hospital Eindhoven, The Netherlands
| | - Loriano Galeotti
- Office of Science and Engineering Laboratories, Center for Devices and Radiological Health, United States Food and Drug Administration, Silver Spring, Maryland
| | | | | | | | - Michael Ringborn
- Department of Cardiology, Lund University, Lund, Sweden/Center for Integrative Electrocardiology at Lund University, Lund, Sweden/Thoracic Center, Blekingesjukhuset, Karlskrona, Sweden; and
| | | | | | - David G Strauss
- Office of Science and Engineering Laboratories, Center for Devices and Radiological Health, United States Food and Drug Administration, Silver Spring, Maryland;
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Akgun T, Kalkan S, Tigen MK. Variations of QRS Morphology in Patients with Dilated Cardiomyopathy; Clinical and Prognostic Implications. J Cardiovasc Thorac Res 2014; 6:85-9. [PMID: 25031822 PMCID: PMC4097857 DOI: 10.5681/jcvtr.2014.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2014] [Accepted: 06/15/2014] [Indexed: 02/04/2023] Open
Abstract
The QRS represents the simultaneous activation of the right and left ventricles, although most of the QRS waveform is derived from the larger left ventricular musculature. Although normal QRS duration is <100 millisecond (ms), its duration and shape are quite variable from patient to patient in idiopathic dilated cardiomyopathy (IDCM). Prolongation of QRS occurs in 14% to 47% of heart failure (HF) patients. Left bundle branch block (LBBB) is far more common than right bundle branch block (RBBB). Dyssynchronous left ventricular activation due to LBBB and other intraventricular conduction blocks provides the rationale for the use of cardiac resynchronization therapy with biventricular pacing in patients with IDCM. Fragmented QRS (fQRS) is a marker of depolarization abnormality and present in significant number of the patients with IDCM and narrow QRS complexes. It is associated with arrhythmic events and intraventricular dyssynchrony. The purpose of this manuscript is to present an overview on some clinical, echocardiographic and prognostic implications of various QRS morphologies in patients with IDCM.
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Affiliation(s)
- Taylan Akgun
- Kartal Kosuyolu Heart & Research Hospital, Department of Cardiology, Istanbul, Turkey
| | - Sedat Kalkan
- Kartal Kosuyolu Heart & Research Hospital, Department of Cardiology, Istanbul, Turkey
| | - Mustafa Kursat Tigen
- Marmara University, Faculty of Medicine, Department of Cardiology, Istanbul, Turkey
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Vernooy K, van Deursen CJM, Strik M, Prinzen FW. Strategies to improve cardiac resynchronization therapy. Nat Rev Cardiol 2014; 11:481-93. [PMID: 24839977 DOI: 10.1038/nrcardio.2014.67] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Cardiac resynchronization therapy (CRT) emerged 2 decades ago as a useful form of device therapy for heart failure associated with abnormal ventricular conduction, indicated by a wide QRS complex. In this Review, we present insights into how to achieve the greatest benefits with this pacemaker therapy. Outcomes from CRT can be improved by appropriate patient selection, careful positioning of right and left ventricular pacing electrodes, and optimal timing of electrode stimulation. Left bundle branch block (LBBB), which can be detected on an electrocardiogram, is the predominant substrate for CRT, and patients with this conduction abnormality yield the most benefit. However, other features, such as QRS morphology, mechanical dyssynchrony, myocardial scarring, and the aetiology of heart failure, might also determine the benefit of CRT. No single left ventricular pacing site suits all patients, but a late-activated site, during either the intrinsic LBBB rhythm or right ventricular pacing, should be selected. Positioning the lead inside a scarred region substantially impairs outcomes. Optimization of stimulation intervals improves cardiac pump function in the short term, but CRT procedures must become easier and more reliable, perhaps with the use of electrocardiographic measures, to improve long-term outcomes.
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Affiliation(s)
- Kevin Vernooy
- Department of Cardiology, Maastricht University Medical Center, PO Box 5800, 6202 AZ Maastricht, Netherlands
| | | | - Marc Strik
- Department of Cardiology, Maastricht University Medical Center, PO Box 5800, 6202 AZ Maastricht, Netherlands
| | - Frits W Prinzen
- Department of Physiology, Maastricht University, PO Box 616, 6200 MD Maastricht, Netherlands
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Comparison of the relation between left ventricular anatomy and QRS duration in patients with cardiomyopathy with versus without left bundle branch block. Am J Cardiol 2014; 113:1717-22. [PMID: 24698465 DOI: 10.1016/j.amjcard.2014.02.026] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2013] [Revised: 02/18/2014] [Accepted: 02/18/2014] [Indexed: 12/12/2022]
Abstract
QRS duration (QRSd) is used to diagnose left bundle branch block (LBBB) and is important to determine cardiac resynchronization therapy eligibility. The same QRSd thresholds established decades ago are used for all patients. However, significant interpatient variability of normal QRSd exists, and individualized QRSd thresholds might improve diagnosis and intervention strategies. Previous work reported left ventricular (LV) mass and papillary muscle location predicted QRSd in healthy subjects, but the relation in diseased ventricles is unknown. The aim of the present study was to determine the association between LV anatomy and QRSd in patients with cardiomyopathy. Patients referred for primary prevention implantable defibrillators (n = 166) received cardiac magnetic resonance imaging, and those with normal conduction (without bundle branch or fascicular block) and LBBB were studied. The LV mass, length, internal diameter, LV end-diastolic volume, septal and lateral wall thicknesses, and papillary muscle location were measured. In patients with normal conduction, LV length (r = 0.35, p <0.001), mass (r = 0.32, p <0.001), diameter (r = 0.20, p = 0.03), and septal wall thickness (r = 0.20, p = 0.03) had positive correlations with QRSd. In patients with LBBB, LV length (r = 0.32, p = 0.03), mass (r = 0.39, p = 0.01), diameter (r = 0.34, p = 0.02), and LV end-diastolic volume (r = 0.32, p = 0.04) had positive correlations with QRSd. Contrary to previous studies in healthy subjects, papillary muscle angle (location) was not associated with QRSd in cardiomyopathy patients with normal conduction or LBBB. In conclusion, increasing LV anatomical measurements were associated with increasing QRSd in patients with cardiomyopathy. Future work should investigate the use of LV anatomical measurements in developing individualized QRSd thresholds for diagnosing conduction abnormalities such as LBBB and identifying candidates for cardiac resynchronization therapy.
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