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Zsigmond EJ, Masszi R, Ehrenberger R, Turan C, Fehérvári P, Gede N, Hegyi P, Molnár Z, Trásy D, Duray GZ. Emergent role of dynamic optimization in cardiac resynchronization therapy: Systematic review and network meta-analysis. ESC Heart Fail 2024. [PMID: 39104128 DOI: 10.1002/ehf2.14957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Revised: 04/01/2024] [Accepted: 04/17/2024] [Indexed: 08/07/2024] Open
Abstract
AIMS Suboptimal device programming is frequent in non-responders to cardiac resynchronization therapy (CRT). However, the role of device optimization and the most appropriate technique are still unknown. The aim of our study was to analyse the effect of different CRT optimization techniques within a network meta-analysis. METHODS A systematic search was conducted on MEDLINE, Embase and CENTRAL for studies comparing outcomes with empirical device settings or optimization using echocardiography, static algorithms or dynamic algorithms. Studies investigating the effect of optimization in non-responders were also analysed. RESULTS A total of 17 studies with 4346 patients were included in the quantitative analysis. Of the treatments and outcomes examined, a significant difference was found only between dynamic algorithms and echocardiography, with the former leading to a higher echocardiographic response rate [odds ratio (OR): 2.02, 95% confidence interval (CI) 1.21-3.35], lower heart failure hospitalization rate (OR: 0.75, 95% CI 0.57-0.99) and greater improvement in 6-minute walk test [mean difference (MD): 45.52 m, 95% credible interval (CrI) 3.91-82.44 m]. We found no significant difference between empirical settings, static algorithms and dynamic algorithms. Seven studies with 228 patients reported response rates after optimization in non-responders. Altogether, 34.3%-66.7% of initial non-responders showed improvement after optimization, depending on response criteria. CONCLUSIONS At the time of CRT implantation, dynamic algorithms may serve as a resource-friendly alternative to echocardiographic optimization, with similar or better mid-term outcomes. However, their superiority over empirical device settings needs to be investigated in further trials. For non-responders, CRT optimization should be considered, as the majority of patients experience improvement.
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Affiliation(s)
- Előd-János Zsigmond
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
- Department of Cardiology, Central Hospital of Northern Pest-Military Hospital, Budapest, Hungary
- Doctoral School of Clinical Medicine, University of Szeged, Szeged, Hungary
| | - Richárd Masszi
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
- Heart and Vascular Centre, Semmelweis University, Budapest, Hungary
| | - Réka Ehrenberger
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
- Heart and Vascular Centre, Semmelweis University, Budapest, Hungary
| | - Caner Turan
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
- Department of Anesthesiology and Intensive Therapy, Semmelweis University, Budapest, Hungary
| | - Péter Fehérvári
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
| | - Noémi Gede
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
| | - Péter Hegyi
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
- Institute of Pancreatic Diseases, Semmelweis University, Budapest, Hungary
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Zsolt Molnár
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
- Department of Anesthesiology and Intensive Therapy, Semmelweis University, Budapest, Hungary
- Department of Anesthesiology and Intensive Therapy, Poznan University of Medical Sciences, Poznań, Poland
| | - Domonkos Trásy
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
| | - Gábor Zoltán Duray
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
- Department of Cardiology, Central Hospital of Northern Pest-Military Hospital, Budapest, Hungary
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Noheria A, Shahab A, Andrews C, Cuculich PS, Rudy Y. Pilot study to evaluate left-to-right ventricular offset in biventricular pacing-comparison of electrocardiographic imaging and ECG. J Cardiovasc Electrophysiol 2024; 35:1185-1195. [PMID: 38591763 DOI: 10.1111/jce.16272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Revised: 03/14/2024] [Accepted: 03/23/2024] [Indexed: 04/10/2024]
Abstract
INTRODUCTION Biventricular pacing (BiVp) improves outcomes in systolic heart failure patients with electrical dyssynchrony. BiVp is delivered from epicardial left ventricular (LV) and endocardial right ventricular (RV) electrodes. Acute electrical activation changes with different LV-RV stimulation offsets can help guide individually optimized BiVp programming. We sought to study the BiVp ventricular activation with different LV-RV offsets and compare with 12-lead ECG. METHODS In five patients with BiVp (63 ± 17-year-old, 80% male, LV ejection fraction 27 ± 6%), we evaluated acute ventricular epicardial activation, varying LV-RV offsets in 20 ms increments from -40 to 80 ms, using electrocardiographic imaging (ECGI) to obtain absolute ventricular electrical uncoupling (VEUabs, absolute difference in average LV and average RV activation time) and total activation time (TAT). For each patient, we calculated the correlation between ECGI and corresponding ECG (3D-QRS-area and QRS duration) with different LV-RV offsets. RESULTS The LV-RV offset to attain minimum VEUabs in individual patients ranged 20-60 ms. In all patients, a larger LV-RV offset was required to achieve minimum VEUabs (36 ± 17 ms) or 3D-QRS-area (40 ± 14 ms) than that for minimum TAT (-4 ± 9 ms) or QRS duration (-8 ± 11 ms). In individual patients, 3D-QRS-area correlated with VEUabs (r 0.65 ± 0.24) and QRS duration correlated with TAT (r 0.95 ± 0.02). Minimum VEUabs and minimum 3D-QRS-area were obtained by LV-RV offset within 20 ms of each other in all five patients. CONCLUSIONS LV-RV electrical uncoupling, as assessed by ECGI, can be minimized by optimizing LV-RV stimulation offset. 3D-QRS-area is a surrogate to identify LV-RV offset that minimizes LV-RV uncoupling.
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Affiliation(s)
- Amit Noheria
- Department of Cardiovascular Medicine, The University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Ahmed Shahab
- Department of Cardiovascular Medicine, The University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Christopher Andrews
- Department of Biomedical Engineering, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Phillip S Cuculich
- Cardiovascular Division, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Yoram Rudy
- Department of Biomedical Engineering, Washington University in St. Louis, St. Louis, Missouri, USA
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Lund-Andersen C, Yafasova A, Høfsten D, Thune JJ, Philbert BT, Nielsen JC, Thøgersen AM, Haarbo J, Videbæk L, Gustafsson F, Svendsen JH, Pehrson S, Køber L. Association between QRS shortening and mortality after cardiac resynchronization therapy: Results from the DANISH study. Int J Cardiol 2024; 399:131700. [PMID: 38168556 DOI: 10.1016/j.ijcard.2023.131700] [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: 10/09/2023] [Revised: 12/22/2023] [Accepted: 12/29/2023] [Indexed: 01/05/2024]
Abstract
BACKGROUND Changes in QRS duration (∆QRS) are often used in the clinical setting to evaluate the effect of cardiac resynchronization therapy (CRT), although an association between ∆QRS and outcomes is not firmly established. We aimed to assess the association between mortality and ∆QRS after CRT in patients from the DANISH (Danish Study to Assess the Efficacy of ICDs in Patients with Non-Ischemic Systolic Heart Failure on Mortality) study. METHODS We included all patients from DANISH who received a CRT device and had available QRS duration data before and after implantation. Cox proportional hazards models were used to assess associations between ∆QRS (post-CRT QRS minus pre-CRT QRS) and mortality. RESULTS Complete data were available in 572 patients. Median baseline QRS duration was 160 ms (IQR [146;180]). Post-CRT QRS was recorded a median of 48 days (IQR [33;86]) after implantation, and the median ∆QRS was -14 ms (IQR [-38;-3]). During a median follow-up of 4.1 years (IQR [2.5;5.8]), 106 patients died. In crude Cox regression, all-cause mortality was reduced by 6% per 10 ms shortening of QRS (HR 0.94; CI: 0.88-1.00, p = 0.04). The effect did not remain significant after multivariable adjustment (HR 1.01, CI: 0.93-1.10, p = 0.77). Further, no association was found between ∆QRS and improvement of New York Heart Association functional class at 6 months (OR 1.03, CI: 0.96-1.10, p = 0.42). CONCLUSION In a large cohort of patients with non-ischemic cardiomyopathy, reduction of QRS duration after CRT was not associated with changes in mortality during long-term follow-up.
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Affiliation(s)
- Casper Lund-Andersen
- Department of Cardiology, The Heart Centre, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Adelina Yafasova
- Department of Cardiology, The Heart Centre, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Dan Høfsten
- Department of Cardiology, The Heart Centre, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Jens Jakob Thune
- Department of Cardiology, Copenhagen University Hospital - Bispebjerg, Copenhagen, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark
| | - Berit T Philbert
- Department of Cardiology, The Heart Centre, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Jens C Nielsen
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Anna M Thøgersen
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
| | - Jens Haarbo
- Department of Cardiology, Copenhagen University Hospital - Gentofte, Gentofte, Denmark
| | - Lars Videbæk
- Department of Cardiology, Odense University Hospital, Odense, Denmark
| | - Finn Gustafsson
- Department of Cardiology, The Heart Centre, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Jesper Hastrup Svendsen
- Department of Cardiology, The Heart Centre, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark
| | - Steen Pehrson
- Department of Cardiology, The Heart Centre, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Lars Køber
- Department of Cardiology, The Heart Centre, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark.
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Vătășescu RG, Târtea GC, Iorgulescu C, Cojocaru C, Deaconu A, Badiul A, Goanță EV, Bogdan Ș, Cozma D. Predictors for Super-Responders in Cardiac Resynchronization Therapy. Am J Ther 2024; 31:e13-e23. [PMID: 38231577 DOI: 10.1097/mjt.0000000000001692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2024]
Abstract
BACKGROUND Prediction of cardiac resynchronization therapy (CRT) response, particularly a super-response, is of great importance. STUDY QUESTION The aim of our study was to assess the predictors for super-responders in CRT. STUDY DESIGN We conducted a retrospective, observational study, which finally included 622 patients with heart failure treated with CRT between January 2008 and May 2020 who had a minimal follow-up of 6 months after CRT. MEASURES AND OUTCOMES A total of 192 super-responders, defined by a left ventricular ejection fraction (LVEF) of at least 45%, and/or minimum 15% increase in LVEF and an improvement of the New York Heart Association functional class by at least 2 degrees at the last follow-up, and the rest of 430 patients who did not fulfill the super-responder criteria. RESULTS The highest rate of super-responders (41.91%, n = 171) was at patients with left ventricle-only pacing with optimal fusion (OPT) compared with patients with biventricular (BiV) pacing (9.81%, n = 21, P < 0.000). In the OPT group, univariable analysis showed that nonischemic cardiomyopathy, a smaller degree of mitral regurgitation, and better left ventricle function at enrollment were predictors for super-response compared with the BiV group where a narrower QRS after implantation, nonischemic cardiomyopathy, and a better baseline LVEF were predictors for super-responders. In the multivariable analysis, both narrower QRS after implantation and nonischemic cardiomyopathy were independent predictors for super-response in the BiV group compared with OPT where nonischemic cardiomyopathy remained the only independent predictor for super-response. CONCLUSIONS In this retrospective study, OPT CRT programing was an additional predictor of super-response to CRT besides nonischemic cardiomyopathy.
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Affiliation(s)
- Radu Gabriel Vătășescu
- Department of Cardiology, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
- Department of Cardiology, Clinic Emergency Hospital of Bucharest, Bucharest, Romania
| | - Georgică Costinel Târtea
- Department of Physiology, University of Medicine and Pharmacy of Craiova, Craiova, Romania
- Department of Cardiology, Emergency County Hospital of Craiova, Craiova, Romania
| | - Corneliu Iorgulescu
- Department of Cardiology, Clinic Emergency Hospital of Bucharest, Bucharest, Romania
| | - Cosmin Cojocaru
- Department of Cardiology, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
- Department of Cardiology, Clinic Emergency Hospital of Bucharest, Bucharest, Romania
| | - Alexandru Deaconu
- Department of Cardiology, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
- Department of Cardiology, Clinic Emergency Hospital of Bucharest, Bucharest, Romania
| | - Alexandru Badiul
- Department of Cardiology, Clinic Emergency Hospital of Bucharest, Bucharest, Romania
| | - Emilia-Violeta Goanță
- Department of Cardiology, Emergency County Hospital of Craiova, Craiova, Romania
- Department of Cardiology, "Victor Babes" University of Medicine and Pharmacy, Timisoara, Romania
| | - Ștefan Bogdan
- Department of Cardiology, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
- Department of Cardiology, "Elias" University Emergency Hospital, Bucharest, Romania; and
| | - Dragoș Cozma
- Department of Cardiology, "Victor Babes" University of Medicine and Pharmacy, Timisoara, Romania
- Institute of Cardiovascular Diseases Timisoara, Timisoara, Romania
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5
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Chung MK, Patton KK, Lau CP, Dal Forno ARJ, Al-Khatib SM, Arora V, Birgersdotter-Green UM, Cha YM, Chung EH, Cronin EM, Curtis AB, Cygankiewicz I, Dandamudi G, Dubin AM, Ensch DP, Glotzer TV, Gold MR, Goldberger ZD, Gopinathannair R, Gorodeski EZ, Gutierrez A, Guzman JC, Huang W, Imrey PB, Indik JH, Karim S, Karpawich PP, Khaykin Y, Kiehl EL, Kron J, Kutyifa V, Link MS, Marine JE, Mullens W, Park SJ, Parkash R, Patete MF, Pathak RK, Perona CA, Rickard J, Schoenfeld MH, Seow SC, Shen WK, Shoda M, Singh JP, Slotwiner DJ, Sridhar ARM, Srivatsa UN, Stecker EC, Tanawuttiwat T, Tang WHW, Tapias CA, Tracy CM, Upadhyay GA, Varma N, Vernooy K, Vijayaraman P, Worsnick SA, Zareba W, Zeitler EP, Lopez-Cabanillas N, Ellenbogen KA, Hua W, Ikeda T, Mackall JA, Mason PK, McLeod CJ, Mela T, Moore JP, Racenet LK. 2023 HRS/APHRS/LAHRS guideline on cardiac physiologic pacing for the avoidance and mitigation of heart failure. J Arrhythm 2023; 39:681-756. [PMID: 37799799 PMCID: PMC10549836 DOI: 10.1002/joa3.12872] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/07/2023] Open
Abstract
Cardiac physiologic pacing (CPP), encompassing cardiac resynchronization therapy (CRT) and conduction system pacing (CSP), has emerged as a pacing therapy strategy that may mitigate or prevent the development of heart failure (HF) in patients with ventricular dyssynchrony or pacing-induced cardiomyopathy. This clinical practice guideline is intended to provide guidance on indications for CRT for HF therapy and CPP in patients with pacemaker indications or HF, patient selection, pre-procedure evaluation and preparation, implant procedure management, follow-up evaluation and optimization of CPP response, and use in pediatric populations. Gaps in knowledge, pointing to new directions for future research, are also identified.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Eugene H Chung
- University of Michigan Medical School Ann Arbor Michigan USA
| | | | | | | | | | - Anne M Dubin
- Stanford University, Pediatric Cardiology Palo Alto California USA
| | - Douglas P Ensch
- Cleveland Clinic Cleveland Ohio USA
- University of Washington Seattle Washington USA
- University of Hong Kong Hong Kong China
- Hospital SOS Cárdio Florianópolis Brazil
- Duke University Medical Center Durham North Carolina USA
- Indraprastha Apollo Hospital New Delhi India
- University of California San Diego Health La Jolla California USA
- Mayo Clinic, Rochester Rochester Minnesota USA
- University of Michigan Medical School Ann Arbor Michigan USA
- Temple University Philadelphia Pennsylvania USA
- University at Buffalo Buffalo New York USA
- Medical University of Łódź, Łódź Poland
- Virginia Mason Franciscan Health Tacoma Washington USA
- Stanford University, Pediatric Cardiology Palo Alto California USA
- Hackensack Meridian School of Medicine Hackensack New Jersey USA
- Medical University of South Carolina Charleston South Carolina USA
- University of Wisconsin School of Medicine and Public Health Madison Wisconsin USA
- Kansas City Heart Rhythm Institute Overland Park Kansas USA
- University Hospitals and Case Western Reserve University School of Medicine Cleveland Ohio USA
- University of Minnesota Minneapolis Minnesota USA
- McMaster University Hamilton Ontario Canada
- First Affiliated Hospital of Wenzhou Medical University Wenzhou China
- Case Western Reserve University Cleveland Ohio USA
- University of Arizona, Sarver Heart Center Tucson Arizona USA
- MetroHealth Medical Center Case Western Reserve University Cleveland Ohio USA
- The Children's Hospital of Michigan Central Michigan University Detroit Michigan USA
- Southlake Regional Health Center Newmarket Ontario Canada
- Sentara Norfolk Virginia USA
- Virginia Commonwealth University Richmond Virginia USA
- University of Rochester Medical Center Rochester New York USA
- University of Texas Southwestern Medical Center Dallas Texas USA
- Johns Hopkins University School of Medicine Baltimore Maryland USA
- Ziekenhuis Oost-Limburg Genk Belgium and Hasselt University Hasselt Belgium
- Sungkyunkwan University School of Medicine, Samsung Medical Center Seoul Republic of Korea
- QEII Health Sciences Center Halifax Nova Scotia Canada
- Clinica Corazones Unidos Santo Domingo Dominican Republic
- Australian National University, Canberra Hospital Garran Australian Capital Territory Australia
- Santojanni Hospital Buenos Aires Argentina
- Yale University School of Medicine New Haven Connecticut USA
- National University Hospital Singapore Singapore
- Mayo Clinic Phoenix Arizona USA
- Tokyo Women's Medical University Tokyo Japan
- Massachusetts General Hospital, Harvard Medical School Boston Massachusetts USA
- Weill Cornell Medicine Population Health Sciences New York New York USA
- University of California Davis Sacramento California USA
- Oregon Health & Science University Portland Oregon USA
- Indiana University Indianapolis Indiana USA
- Fundación Cardioinfantil Instituto de Cardiologia Bogotá Colombia
- George Washington University Washington District of Columbia USA
- University of Chicago Medicine Chicago Illinois USA
- Cardiovascular Research Institute Maastricht, Maastricht University Medical Center Maastricht The Netherlands
- Geisinger Health System Wilkes-Barre Pennsylvania USA
- Dartmouth Hitchcock Medical Center New Hampshire Lebanon
| | - Taya V Glotzer
- Hackensack Meridian School of Medicine Hackensack New Jersey USA
| | - Michael R Gold
- Medical University of South Carolina Charleston South Carolina USA
| | - Zachary D Goldberger
- University of Wisconsin School of Medicine and Public Health Madison Wisconsin USA
| | | | - Eiran Z Gorodeski
- University Hospitals and Case Western Reserve University School of Medicine Cleveland Ohio USA
| | | | | | - Weijian Huang
- First Affiliated Hospital of Wenzhou Medical University Wenzhou China
| | - Peter B Imrey
- Cleveland Clinic Cleveland Ohio USA
- Case Western Reserve University Cleveland Ohio USA
| | - Julia H Indik
- University of Arizona, Sarver Heart Center Tucson Arizona USA
| | - Saima Karim
- MetroHealth Medical Center Case Western Reserve University Cleveland Ohio USA
| | - Peter P Karpawich
- The Children's Hospital of Michigan Central Michigan University Detroit Michigan USA
| | - Yaariv Khaykin
- Southlake Regional Health Center Newmarket Ontario Canada
| | | | - Jordana Kron
- Virginia Commonwealth University Richmond Virginia USA
| | | | - Mark S Link
- University of Texas Southwestern Medical Center Dallas Texas USA
| | - Joseph E Marine
- Johns Hopkins University School of Medicine Baltimore Maryland USA
| | - Wilfried Mullens
- Ziekenhuis Oost-Limburg Genk Belgium and Hasselt University Hasselt Belgium
| | - Seung-Jung Park
- Sungkyunkwan University School of Medicine, Samsung Medical Center Seoul Republic of Korea
| | | | | | - Rajeev Kumar Pathak
- Australian National University, Canberra Hospital Garran Australian Capital Territory Australia
| | | | | | | | | | | | - Morio Shoda
- Tokyo Women's Medical University Tokyo Japan
| | - Jagmeet P Singh
- Massachusetts General Hospital, Harvard Medical School Boston Massachusetts USA
| | - David J Slotwiner
- Weill Cornell Medicine Population Health Sciences New York New York USA
| | | | - Uma N Srivatsa
- University of California Davis Sacramento California USA
| | | | | | | | | | - Cynthia M Tracy
- George Washington University Washington District of Columbia USA
| | | | | | - Kevin Vernooy
- Cardiovascular Research Institute Maastricht, Maastricht University Medical Center Maastricht The Netherlands
| | | | | | - Wojciech Zareba
- University of Rochester Medical Center Rochester New York USA
| | | | - Nestor Lopez-Cabanillas
- Cleveland Clinic Cleveland Ohio USA
- University of Washington Seattle Washington USA
- University of Hong Kong Hong Kong China
- Hospital SOS Cárdio Florianópolis Brazil
- Duke University Medical Center Durham North Carolina USA
- Indraprastha Apollo Hospital New Delhi India
- University of California San Diego Health La Jolla California USA
- Mayo Clinic, Rochester Rochester Minnesota USA
- University of Michigan Medical School Ann Arbor Michigan USA
- Temple University Philadelphia Pennsylvania USA
- University at Buffalo Buffalo New York USA
- Medical University of Łódź, Łódź Poland
- Virginia Mason Franciscan Health Tacoma Washington USA
- Stanford University, Pediatric Cardiology Palo Alto California USA
- Hackensack Meridian School of Medicine Hackensack New Jersey USA
- Medical University of South Carolina Charleston South Carolina USA
- University of Wisconsin School of Medicine and Public Health Madison Wisconsin USA
- Kansas City Heart Rhythm Institute Overland Park Kansas USA
- University Hospitals and Case Western Reserve University School of Medicine Cleveland Ohio USA
- University of Minnesota Minneapolis Minnesota USA
- McMaster University Hamilton Ontario Canada
- First Affiliated Hospital of Wenzhou Medical University Wenzhou China
- Case Western Reserve University Cleveland Ohio USA
- University of Arizona, Sarver Heart Center Tucson Arizona USA
- MetroHealth Medical Center Case Western Reserve University Cleveland Ohio USA
- The Children's Hospital of Michigan Central Michigan University Detroit Michigan USA
- Southlake Regional Health Center Newmarket Ontario Canada
- Sentara Norfolk Virginia USA
- Virginia Commonwealth University Richmond Virginia USA
- University of Rochester Medical Center Rochester New York USA
- University of Texas Southwestern Medical Center Dallas Texas USA
- Johns Hopkins University School of Medicine Baltimore Maryland USA
- Ziekenhuis Oost-Limburg Genk Belgium and Hasselt University Hasselt Belgium
- Sungkyunkwan University School of Medicine, Samsung Medical Center Seoul Republic of Korea
- QEII Health Sciences Center Halifax Nova Scotia Canada
- Clinica Corazones Unidos Santo Domingo Dominican Republic
- Australian National University, Canberra Hospital Garran Australian Capital Territory Australia
- Santojanni Hospital Buenos Aires Argentina
- Yale University School of Medicine New Haven Connecticut USA
- National University Hospital Singapore Singapore
- Mayo Clinic Phoenix Arizona USA
- Tokyo Women's Medical University Tokyo Japan
- Massachusetts General Hospital, Harvard Medical School Boston Massachusetts USA
- Weill Cornell Medicine Population Health Sciences New York New York USA
- University of California Davis Sacramento California USA
- Oregon Health & Science University Portland Oregon USA
- Indiana University Indianapolis Indiana USA
- Fundación Cardioinfantil Instituto de Cardiologia Bogotá Colombia
- George Washington University Washington District of Columbia USA
- University of Chicago Medicine Chicago Illinois USA
- Cardiovascular Research Institute Maastricht, Maastricht University Medical Center Maastricht The Netherlands
- Geisinger Health System Wilkes-Barre Pennsylvania USA
- Dartmouth Hitchcock Medical Center New Hampshire Lebanon
| | - Kenneth A Ellenbogen
- Cleveland Clinic Cleveland Ohio USA
- University of Washington Seattle Washington USA
- University of Hong Kong Hong Kong China
- Hospital SOS Cárdio Florianópolis Brazil
- Duke University Medical Center Durham North Carolina USA
- Indraprastha Apollo Hospital New Delhi India
- University of California San Diego Health La Jolla California USA
- Mayo Clinic, Rochester Rochester Minnesota USA
- University of Michigan Medical School Ann Arbor Michigan USA
- Temple University Philadelphia Pennsylvania USA
- University at Buffalo Buffalo New York USA
- Medical University of Łódź, Łódź Poland
- Virginia Mason Franciscan Health Tacoma Washington USA
- Stanford University, Pediatric Cardiology Palo Alto California USA
- Hackensack Meridian School of Medicine Hackensack New Jersey USA
- Medical University of South Carolina Charleston South Carolina USA
- University of Wisconsin School of Medicine and Public Health Madison Wisconsin USA
- Kansas City Heart Rhythm Institute Overland Park Kansas USA
- University Hospitals and Case Western Reserve University School of Medicine Cleveland Ohio USA
- University of Minnesota Minneapolis Minnesota USA
- McMaster University Hamilton Ontario Canada
- First Affiliated Hospital of Wenzhou Medical University Wenzhou China
- Case Western Reserve University Cleveland Ohio USA
- University of Arizona, Sarver Heart Center Tucson Arizona USA
- MetroHealth Medical Center Case Western Reserve University Cleveland Ohio USA
- The Children's Hospital of Michigan Central Michigan University Detroit Michigan USA
- Southlake Regional Health Center Newmarket Ontario Canada
- Sentara Norfolk Virginia USA
- Virginia Commonwealth University Richmond Virginia USA
- University of Rochester Medical Center Rochester New York USA
- University of Texas Southwestern Medical Center Dallas Texas USA
- Johns Hopkins University School of Medicine Baltimore Maryland USA
- Ziekenhuis Oost-Limburg Genk Belgium and Hasselt University Hasselt Belgium
- Sungkyunkwan University School of Medicine, Samsung Medical Center Seoul Republic of Korea
- QEII Health Sciences Center Halifax Nova Scotia Canada
- Clinica Corazones Unidos Santo Domingo Dominican Republic
- Australian National University, Canberra Hospital Garran Australian Capital Territory Australia
- Santojanni Hospital Buenos Aires Argentina
- Yale University School of Medicine New Haven Connecticut USA
- National University Hospital Singapore Singapore
- Mayo Clinic Phoenix Arizona USA
- Tokyo Women's Medical University Tokyo Japan
- Massachusetts General Hospital, Harvard Medical School Boston Massachusetts USA
- Weill Cornell Medicine Population Health Sciences New York New York USA
- University of California Davis Sacramento California USA
- Oregon Health & Science University Portland Oregon USA
- Indiana University Indianapolis Indiana USA
- Fundación Cardioinfantil Instituto de Cardiologia Bogotá Colombia
- George Washington University Washington District of Columbia USA
- University of Chicago Medicine Chicago Illinois USA
- Cardiovascular Research Institute Maastricht, Maastricht University Medical Center Maastricht The Netherlands
- Geisinger Health System Wilkes-Barre Pennsylvania USA
- Dartmouth Hitchcock Medical Center New Hampshire Lebanon
| | - Wei Hua
- Cleveland Clinic Cleveland Ohio USA
- University of Washington Seattle Washington USA
- University of Hong Kong Hong Kong China
- Hospital SOS Cárdio Florianópolis Brazil
- Duke University Medical Center Durham North Carolina USA
- Indraprastha Apollo Hospital New Delhi India
- University of California San Diego Health La Jolla California USA
- Mayo Clinic, Rochester Rochester Minnesota USA
- University of Michigan Medical School Ann Arbor Michigan USA
- Temple University Philadelphia Pennsylvania USA
- University at Buffalo Buffalo New York USA
- Medical University of Łódź, Łódź Poland
- Virginia Mason Franciscan Health Tacoma Washington USA
- Stanford University, Pediatric Cardiology Palo Alto California USA
- Hackensack Meridian School of Medicine Hackensack New Jersey USA
- Medical University of South Carolina Charleston South Carolina USA
- University of Wisconsin School of Medicine and Public Health Madison Wisconsin USA
- Kansas City Heart Rhythm Institute Overland Park Kansas USA
- University Hospitals and Case Western Reserve University School of Medicine Cleveland Ohio USA
- University of Minnesota Minneapolis Minnesota USA
- McMaster University Hamilton Ontario Canada
- First Affiliated Hospital of Wenzhou Medical University Wenzhou China
- Case Western Reserve University Cleveland Ohio USA
- University of Arizona, Sarver Heart Center Tucson Arizona USA
- MetroHealth Medical Center Case Western Reserve University Cleveland Ohio USA
- The Children's Hospital of Michigan Central Michigan University Detroit Michigan USA
- Southlake Regional Health Center Newmarket Ontario Canada
- Sentara Norfolk Virginia USA
- Virginia Commonwealth University Richmond Virginia USA
- University of Rochester Medical Center Rochester New York USA
- University of Texas Southwestern Medical Center Dallas Texas USA
- Johns Hopkins University School of Medicine Baltimore Maryland USA
- Ziekenhuis Oost-Limburg Genk Belgium and Hasselt University Hasselt Belgium
- Sungkyunkwan University School of Medicine, Samsung Medical Center Seoul Republic of Korea
- QEII Health Sciences Center Halifax Nova Scotia Canada
- Clinica Corazones Unidos Santo Domingo Dominican Republic
- Australian National University, Canberra Hospital Garran Australian Capital Territory Australia
- Santojanni Hospital Buenos Aires Argentina
- Yale University School of Medicine New Haven Connecticut USA
- National University Hospital Singapore Singapore
- Mayo Clinic Phoenix Arizona USA
- Tokyo Women's Medical University Tokyo Japan
- Massachusetts General Hospital, Harvard Medical School Boston Massachusetts USA
- Weill Cornell Medicine Population Health Sciences New York New York USA
- University of California Davis Sacramento California USA
- Oregon Health & Science University Portland Oregon USA
- Indiana University Indianapolis Indiana USA
- Fundación Cardioinfantil Instituto de Cardiologia Bogotá Colombia
- George Washington University Washington District of Columbia USA
- University of Chicago Medicine Chicago Illinois USA
- Cardiovascular Research Institute Maastricht, Maastricht University Medical Center Maastricht The Netherlands
- Geisinger Health System Wilkes-Barre Pennsylvania USA
- Dartmouth Hitchcock Medical Center New Hampshire Lebanon
| | - Takanori Ikeda
- Cleveland Clinic Cleveland Ohio USA
- University of Washington Seattle Washington USA
- University of Hong Kong Hong Kong China
- Hospital SOS Cárdio Florianópolis Brazil
- Duke University Medical Center Durham North Carolina USA
- Indraprastha Apollo Hospital New Delhi India
- University of California San Diego Health La Jolla California USA
- Mayo Clinic, Rochester Rochester Minnesota USA
- University of Michigan Medical School Ann Arbor Michigan USA
- Temple University Philadelphia Pennsylvania USA
- University at Buffalo Buffalo New York USA
- Medical University of Łódź, Łódź Poland
- Virginia Mason Franciscan Health Tacoma Washington USA
- Stanford University, Pediatric Cardiology Palo Alto California USA
- Hackensack Meridian School of Medicine Hackensack New Jersey USA
- Medical University of South Carolina Charleston South Carolina USA
- University of Wisconsin School of Medicine and Public Health Madison Wisconsin USA
- Kansas City Heart Rhythm Institute Overland Park Kansas USA
- University Hospitals and Case Western Reserve University School of Medicine Cleveland Ohio USA
- University of Minnesota Minneapolis Minnesota USA
- McMaster University Hamilton Ontario Canada
- First Affiliated Hospital of Wenzhou Medical University Wenzhou China
- Case Western Reserve University Cleveland Ohio USA
- University of Arizona, Sarver Heart Center Tucson Arizona USA
- MetroHealth Medical Center Case Western Reserve University Cleveland Ohio USA
- The Children's Hospital of Michigan Central Michigan University Detroit Michigan USA
- Southlake Regional Health Center Newmarket Ontario Canada
- Sentara Norfolk Virginia USA
- Virginia Commonwealth University Richmond Virginia USA
- University of Rochester Medical Center Rochester New York USA
- University of Texas Southwestern Medical Center Dallas Texas USA
- Johns Hopkins University School of Medicine Baltimore Maryland USA
- Ziekenhuis Oost-Limburg Genk Belgium and Hasselt University Hasselt Belgium
- Sungkyunkwan University School of Medicine, Samsung Medical Center Seoul Republic of Korea
- QEII Health Sciences Center Halifax Nova Scotia Canada
- Clinica Corazones Unidos Santo Domingo Dominican Republic
- Australian National University, Canberra Hospital Garran Australian Capital Territory Australia
- Santojanni Hospital Buenos Aires Argentina
- Yale University School of Medicine New Haven Connecticut USA
- National University Hospital Singapore Singapore
- Mayo Clinic Phoenix Arizona USA
- Tokyo Women's Medical University Tokyo Japan
- Massachusetts General Hospital, Harvard Medical School Boston Massachusetts USA
- Weill Cornell Medicine Population Health Sciences New York New York USA
- University of California Davis Sacramento California USA
- Oregon Health & Science University Portland Oregon USA
- Indiana University Indianapolis Indiana USA
- Fundación Cardioinfantil Instituto de Cardiologia Bogotá Colombia
- George Washington University Washington District of Columbia USA
- University of Chicago Medicine Chicago Illinois USA
- Cardiovascular Research Institute Maastricht, Maastricht University Medical Center Maastricht The Netherlands
- Geisinger Health System Wilkes-Barre Pennsylvania USA
- Dartmouth Hitchcock Medical Center New Hampshire Lebanon
| | - Judith A Mackall
- Cleveland Clinic Cleveland Ohio USA
- University of Washington Seattle Washington USA
- University of Hong Kong Hong Kong China
- Hospital SOS Cárdio Florianópolis Brazil
- Duke University Medical Center Durham North Carolina USA
- Indraprastha Apollo Hospital New Delhi India
- University of California San Diego Health La Jolla California USA
- Mayo Clinic, Rochester Rochester Minnesota USA
- University of Michigan Medical School Ann Arbor Michigan USA
- Temple University Philadelphia Pennsylvania USA
- University at Buffalo Buffalo New York USA
- Medical University of Łódź, Łódź Poland
- Virginia Mason Franciscan Health Tacoma Washington USA
- Stanford University, Pediatric Cardiology Palo Alto California USA
- Hackensack Meridian School of Medicine Hackensack New Jersey USA
- Medical University of South Carolina Charleston South Carolina USA
- University of Wisconsin School of Medicine and Public Health Madison Wisconsin USA
- Kansas City Heart Rhythm Institute Overland Park Kansas USA
- University Hospitals and Case Western Reserve University School of Medicine Cleveland Ohio USA
- University of Minnesota Minneapolis Minnesota USA
- McMaster University Hamilton Ontario Canada
- First Affiliated Hospital of Wenzhou Medical University Wenzhou China
- Case Western Reserve University Cleveland Ohio USA
- University of Arizona, Sarver Heart Center Tucson Arizona USA
- MetroHealth Medical Center Case Western Reserve University Cleveland Ohio USA
- The Children's Hospital of Michigan Central Michigan University Detroit Michigan USA
- Southlake Regional Health Center Newmarket Ontario Canada
- Sentara Norfolk Virginia USA
- Virginia Commonwealth University Richmond Virginia USA
- University of Rochester Medical Center Rochester New York USA
- University of Texas Southwestern Medical Center Dallas Texas USA
- Johns Hopkins University School of Medicine Baltimore Maryland USA
- Ziekenhuis Oost-Limburg Genk Belgium and Hasselt University Hasselt Belgium
- Sungkyunkwan University School of Medicine, Samsung Medical Center Seoul Republic of Korea
- QEII Health Sciences Center Halifax Nova Scotia Canada
- Clinica Corazones Unidos Santo Domingo Dominican Republic
- Australian National University, Canberra Hospital Garran Australian Capital Territory Australia
- Santojanni Hospital Buenos Aires Argentina
- Yale University School of Medicine New Haven Connecticut USA
- National University Hospital Singapore Singapore
- Mayo Clinic Phoenix Arizona USA
- Tokyo Women's Medical University Tokyo Japan
- Massachusetts General Hospital, Harvard Medical School Boston Massachusetts USA
- Weill Cornell Medicine Population Health Sciences New York New York USA
- University of California Davis Sacramento California USA
- Oregon Health & Science University Portland Oregon USA
- Indiana University Indianapolis Indiana USA
- Fundación Cardioinfantil Instituto de Cardiologia Bogotá Colombia
- George Washington University Washington District of Columbia USA
- University of Chicago Medicine Chicago Illinois USA
- Cardiovascular Research Institute Maastricht, Maastricht University Medical Center Maastricht The Netherlands
- Geisinger Health System Wilkes-Barre Pennsylvania USA
- Dartmouth Hitchcock Medical Center New Hampshire Lebanon
| | - Pamela K Mason
- Cleveland Clinic Cleveland Ohio USA
- University of Washington Seattle Washington USA
- University of Hong Kong Hong Kong China
- Hospital SOS Cárdio Florianópolis Brazil
- Duke University Medical Center Durham North Carolina USA
- Indraprastha Apollo Hospital New Delhi India
- University of California San Diego Health La Jolla California USA
- Mayo Clinic, Rochester Rochester Minnesota USA
- University of Michigan Medical School Ann Arbor Michigan USA
- Temple University Philadelphia Pennsylvania USA
- University at Buffalo Buffalo New York USA
- Medical University of Łódź, Łódź Poland
- Virginia Mason Franciscan Health Tacoma Washington USA
- Stanford University, Pediatric Cardiology Palo Alto California USA
- Hackensack Meridian School of Medicine Hackensack New Jersey USA
- Medical University of South Carolina Charleston South Carolina USA
- University of Wisconsin School of Medicine and Public Health Madison Wisconsin USA
- Kansas City Heart Rhythm Institute Overland Park Kansas USA
- University Hospitals and Case Western Reserve University School of Medicine Cleveland Ohio USA
- University of Minnesota Minneapolis Minnesota USA
- McMaster University Hamilton Ontario Canada
- First Affiliated Hospital of Wenzhou Medical University Wenzhou China
- Case Western Reserve University Cleveland Ohio USA
- University of Arizona, Sarver Heart Center Tucson Arizona USA
- MetroHealth Medical Center Case Western Reserve University Cleveland Ohio USA
- The Children's Hospital of Michigan Central Michigan University Detroit Michigan USA
- Southlake Regional Health Center Newmarket Ontario Canada
- Sentara Norfolk Virginia USA
- Virginia Commonwealth University Richmond Virginia USA
- University of Rochester Medical Center Rochester New York USA
- University of Texas Southwestern Medical Center Dallas Texas USA
- Johns Hopkins University School of Medicine Baltimore Maryland USA
- Ziekenhuis Oost-Limburg Genk Belgium and Hasselt University Hasselt Belgium
- Sungkyunkwan University School of Medicine, Samsung Medical Center Seoul Republic of Korea
- QEII Health Sciences Center Halifax Nova Scotia Canada
- Clinica Corazones Unidos Santo Domingo Dominican Republic
- Australian National University, Canberra Hospital Garran Australian Capital Territory Australia
- Santojanni Hospital Buenos Aires Argentina
- Yale University School of Medicine New Haven Connecticut USA
- National University Hospital Singapore Singapore
- Mayo Clinic Phoenix Arizona USA
- Tokyo Women's Medical University Tokyo Japan
- Massachusetts General Hospital, Harvard Medical School Boston Massachusetts USA
- Weill Cornell Medicine Population Health Sciences New York New York USA
- University of California Davis Sacramento California USA
- Oregon Health & Science University Portland Oregon USA
- Indiana University Indianapolis Indiana USA
- Fundación Cardioinfantil Instituto de Cardiologia Bogotá Colombia
- George Washington University Washington District of Columbia USA
- University of Chicago Medicine Chicago Illinois USA
- Cardiovascular Research Institute Maastricht, Maastricht University Medical Center Maastricht The Netherlands
- Geisinger Health System Wilkes-Barre Pennsylvania USA
- Dartmouth Hitchcock Medical Center New Hampshire Lebanon
| | - Christopher J McLeod
- Cleveland Clinic Cleveland Ohio USA
- University of Washington Seattle Washington USA
- University of Hong Kong Hong Kong China
- Hospital SOS Cárdio Florianópolis Brazil
- Duke University Medical Center Durham North Carolina USA
- Indraprastha Apollo Hospital New Delhi India
- University of California San Diego Health La Jolla California USA
- Mayo Clinic, Rochester Rochester Minnesota USA
- University of Michigan Medical School Ann Arbor Michigan USA
- Temple University Philadelphia Pennsylvania USA
- University at Buffalo Buffalo New York USA
- Medical University of Łódź, Łódź Poland
- Virginia Mason Franciscan Health Tacoma Washington USA
- Stanford University, Pediatric Cardiology Palo Alto California USA
- Hackensack Meridian School of Medicine Hackensack New Jersey USA
- Medical University of South Carolina Charleston South Carolina USA
- University of Wisconsin School of Medicine and Public Health Madison Wisconsin USA
- Kansas City Heart Rhythm Institute Overland Park Kansas USA
- University Hospitals and Case Western Reserve University School of Medicine Cleveland Ohio USA
- University of Minnesota Minneapolis Minnesota USA
- McMaster University Hamilton Ontario Canada
- First Affiliated Hospital of Wenzhou Medical University Wenzhou China
- Case Western Reserve University Cleveland Ohio USA
- University of Arizona, Sarver Heart Center Tucson Arizona USA
- MetroHealth Medical Center Case Western Reserve University Cleveland Ohio USA
- The Children's Hospital of Michigan Central Michigan University Detroit Michigan USA
- Southlake Regional Health Center Newmarket Ontario Canada
- Sentara Norfolk Virginia USA
- Virginia Commonwealth University Richmond Virginia USA
- University of Rochester Medical Center Rochester New York USA
- University of Texas Southwestern Medical Center Dallas Texas USA
- Johns Hopkins University School of Medicine Baltimore Maryland USA
- Ziekenhuis Oost-Limburg Genk Belgium and Hasselt University Hasselt Belgium
- Sungkyunkwan University School of Medicine, Samsung Medical Center Seoul Republic of Korea
- QEII Health Sciences Center Halifax Nova Scotia Canada
- Clinica Corazones Unidos Santo Domingo Dominican Republic
- Australian National University, Canberra Hospital Garran Australian Capital Territory Australia
- Santojanni Hospital Buenos Aires Argentina
- Yale University School of Medicine New Haven Connecticut USA
- National University Hospital Singapore Singapore
- Mayo Clinic Phoenix Arizona USA
- Tokyo Women's Medical University Tokyo Japan
- Massachusetts General Hospital, Harvard Medical School Boston Massachusetts USA
- Weill Cornell Medicine Population Health Sciences New York New York USA
- University of California Davis Sacramento California USA
- Oregon Health & Science University Portland Oregon USA
- Indiana University Indianapolis Indiana USA
- Fundación Cardioinfantil Instituto de Cardiologia Bogotá Colombia
- George Washington University Washington District of Columbia USA
- University of Chicago Medicine Chicago Illinois USA
- Cardiovascular Research Institute Maastricht, Maastricht University Medical Center Maastricht The Netherlands
- Geisinger Health System Wilkes-Barre Pennsylvania USA
- Dartmouth Hitchcock Medical Center New Hampshire Lebanon
| | - Theofanie Mela
- Cleveland Clinic Cleveland Ohio USA
- University of Washington Seattle Washington USA
- University of Hong Kong Hong Kong China
- Hospital SOS Cárdio Florianópolis Brazil
- Duke University Medical Center Durham North Carolina USA
- Indraprastha Apollo Hospital New Delhi India
- University of California San Diego Health La Jolla California USA
- Mayo Clinic, Rochester Rochester Minnesota USA
- University of Michigan Medical School Ann Arbor Michigan USA
- Temple University Philadelphia Pennsylvania USA
- University at Buffalo Buffalo New York USA
- Medical University of Łódź, Łódź Poland
- Virginia Mason Franciscan Health Tacoma Washington USA
- Stanford University, Pediatric Cardiology Palo Alto California USA
- Hackensack Meridian School of Medicine Hackensack New Jersey USA
- Medical University of South Carolina Charleston South Carolina USA
- University of Wisconsin School of Medicine and Public Health Madison Wisconsin USA
- Kansas City Heart Rhythm Institute Overland Park Kansas USA
- University Hospitals and Case Western Reserve University School of Medicine Cleveland Ohio USA
- University of Minnesota Minneapolis Minnesota USA
- McMaster University Hamilton Ontario Canada
- First Affiliated Hospital of Wenzhou Medical University Wenzhou China
- Case Western Reserve University Cleveland Ohio USA
- University of Arizona, Sarver Heart Center Tucson Arizona USA
- MetroHealth Medical Center Case Western Reserve University Cleveland Ohio USA
- The Children's Hospital of Michigan Central Michigan University Detroit Michigan USA
- Southlake Regional Health Center Newmarket Ontario Canada
- Sentara Norfolk Virginia USA
- Virginia Commonwealth University Richmond Virginia USA
- University of Rochester Medical Center Rochester New York USA
- University of Texas Southwestern Medical Center Dallas Texas USA
- Johns Hopkins University School of Medicine Baltimore Maryland USA
- Ziekenhuis Oost-Limburg Genk Belgium and Hasselt University Hasselt Belgium
- Sungkyunkwan University School of Medicine, Samsung Medical Center Seoul Republic of Korea
- QEII Health Sciences Center Halifax Nova Scotia Canada
- Clinica Corazones Unidos Santo Domingo Dominican Republic
- Australian National University, Canberra Hospital Garran Australian Capital Territory Australia
- Santojanni Hospital Buenos Aires Argentina
- Yale University School of Medicine New Haven Connecticut USA
- National University Hospital Singapore Singapore
- Mayo Clinic Phoenix Arizona USA
- Tokyo Women's Medical University Tokyo Japan
- Massachusetts General Hospital, Harvard Medical School Boston Massachusetts USA
- Weill Cornell Medicine Population Health Sciences New York New York USA
- University of California Davis Sacramento California USA
- Oregon Health & Science University Portland Oregon USA
- Indiana University Indianapolis Indiana USA
- Fundación Cardioinfantil Instituto de Cardiologia Bogotá Colombia
- George Washington University Washington District of Columbia USA
- University of Chicago Medicine Chicago Illinois USA
- Cardiovascular Research Institute Maastricht, Maastricht University Medical Center Maastricht The Netherlands
- Geisinger Health System Wilkes-Barre Pennsylvania USA
- Dartmouth Hitchcock Medical Center New Hampshire Lebanon
| | - Jeremy P Moore
- Cleveland Clinic Cleveland Ohio USA
- University of Washington Seattle Washington USA
- University of Hong Kong Hong Kong China
- Hospital SOS Cárdio Florianópolis Brazil
- Duke University Medical Center Durham North Carolina USA
- Indraprastha Apollo Hospital New Delhi India
- University of California San Diego Health La Jolla California USA
- Mayo Clinic, Rochester Rochester Minnesota USA
- University of Michigan Medical School Ann Arbor Michigan USA
- Temple University Philadelphia Pennsylvania USA
- University at Buffalo Buffalo New York USA
- Medical University of Łódź, Łódź Poland
- Virginia Mason Franciscan Health Tacoma Washington USA
- Stanford University, Pediatric Cardiology Palo Alto California USA
- Hackensack Meridian School of Medicine Hackensack New Jersey USA
- Medical University of South Carolina Charleston South Carolina USA
- University of Wisconsin School of Medicine and Public Health Madison Wisconsin USA
- Kansas City Heart Rhythm Institute Overland Park Kansas USA
- University Hospitals and Case Western Reserve University School of Medicine Cleveland Ohio USA
- University of Minnesota Minneapolis Minnesota USA
- McMaster University Hamilton Ontario Canada
- First Affiliated Hospital of Wenzhou Medical University Wenzhou China
- Case Western Reserve University Cleveland Ohio USA
- University of Arizona, Sarver Heart Center Tucson Arizona USA
- MetroHealth Medical Center Case Western Reserve University Cleveland Ohio USA
- The Children's Hospital of Michigan Central Michigan University Detroit Michigan USA
- Southlake Regional Health Center Newmarket Ontario Canada
- Sentara Norfolk Virginia USA
- Virginia Commonwealth University Richmond Virginia USA
- University of Rochester Medical Center Rochester New York USA
- University of Texas Southwestern Medical Center Dallas Texas USA
- Johns Hopkins University School of Medicine Baltimore Maryland USA
- Ziekenhuis Oost-Limburg Genk Belgium and Hasselt University Hasselt Belgium
- Sungkyunkwan University School of Medicine, Samsung Medical Center Seoul Republic of Korea
- QEII Health Sciences Center Halifax Nova Scotia Canada
- Clinica Corazones Unidos Santo Domingo Dominican Republic
- Australian National University, Canberra Hospital Garran Australian Capital Territory Australia
- Santojanni Hospital Buenos Aires Argentina
- Yale University School of Medicine New Haven Connecticut USA
- National University Hospital Singapore Singapore
- Mayo Clinic Phoenix Arizona USA
- Tokyo Women's Medical University Tokyo Japan
- Massachusetts General Hospital, Harvard Medical School Boston Massachusetts USA
- Weill Cornell Medicine Population Health Sciences New York New York USA
- University of California Davis Sacramento California USA
- Oregon Health & Science University Portland Oregon USA
- Indiana University Indianapolis Indiana USA
- Fundación Cardioinfantil Instituto de Cardiologia Bogotá Colombia
- George Washington University Washington District of Columbia USA
- University of Chicago Medicine Chicago Illinois USA
- Cardiovascular Research Institute Maastricht, Maastricht University Medical Center Maastricht The Netherlands
- Geisinger Health System Wilkes-Barre Pennsylvania USA
- Dartmouth Hitchcock Medical Center New Hampshire Lebanon
| | - Laurel Kay Racenet
- Cleveland Clinic Cleveland Ohio USA
- University of Washington Seattle Washington USA
- University of Hong Kong Hong Kong China
- Hospital SOS Cárdio Florianópolis Brazil
- Duke University Medical Center Durham North Carolina USA
- Indraprastha Apollo Hospital New Delhi India
- University of California San Diego Health La Jolla California USA
- Mayo Clinic, Rochester Rochester Minnesota USA
- University of Michigan Medical School Ann Arbor Michigan USA
- Temple University Philadelphia Pennsylvania USA
- University at Buffalo Buffalo New York USA
- Medical University of Łódź, Łódź Poland
- Virginia Mason Franciscan Health Tacoma Washington USA
- Stanford University, Pediatric Cardiology Palo Alto California USA
- Hackensack Meridian School of Medicine Hackensack New Jersey USA
- Medical University of South Carolina Charleston South Carolina USA
- University of Wisconsin School of Medicine and Public Health Madison Wisconsin USA
- Kansas City Heart Rhythm Institute Overland Park Kansas USA
- University Hospitals and Case Western Reserve University School of Medicine Cleveland Ohio USA
- University of Minnesota Minneapolis Minnesota USA
- McMaster University Hamilton Ontario Canada
- First Affiliated Hospital of Wenzhou Medical University Wenzhou China
- Case Western Reserve University Cleveland Ohio USA
- University of Arizona, Sarver Heart Center Tucson Arizona USA
- MetroHealth Medical Center Case Western Reserve University Cleveland Ohio USA
- The Children's Hospital of Michigan Central Michigan University Detroit Michigan USA
- Southlake Regional Health Center Newmarket Ontario Canada
- Sentara Norfolk Virginia USA
- Virginia Commonwealth University Richmond Virginia USA
- University of Rochester Medical Center Rochester New York USA
- University of Texas Southwestern Medical Center Dallas Texas USA
- Johns Hopkins University School of Medicine Baltimore Maryland USA
- Ziekenhuis Oost-Limburg Genk Belgium and Hasselt University Hasselt Belgium
- Sungkyunkwan University School of Medicine, Samsung Medical Center Seoul Republic of Korea
- QEII Health Sciences Center Halifax Nova Scotia Canada
- Clinica Corazones Unidos Santo Domingo Dominican Republic
- Australian National University, Canberra Hospital Garran Australian Capital Territory Australia
- Santojanni Hospital Buenos Aires Argentina
- Yale University School of Medicine New Haven Connecticut USA
- National University Hospital Singapore Singapore
- Mayo Clinic Phoenix Arizona USA
- Tokyo Women's Medical University Tokyo Japan
- Massachusetts General Hospital, Harvard Medical School Boston Massachusetts USA
- Weill Cornell Medicine Population Health Sciences New York New York USA
- University of California Davis Sacramento California USA
- Oregon Health & Science University Portland Oregon USA
- Indiana University Indianapolis Indiana USA
- Fundación Cardioinfantil Instituto de Cardiologia Bogotá Colombia
- George Washington University Washington District of Columbia USA
- University of Chicago Medicine Chicago Illinois USA
- Cardiovascular Research Institute Maastricht, Maastricht University Medical Center Maastricht The Netherlands
- Geisinger Health System Wilkes-Barre Pennsylvania USA
- Dartmouth Hitchcock Medical Center New Hampshire Lebanon
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6
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Chung MK, Patton KK, Lau CP, Dal Forno ARJ, Al-Khatib SM, Arora V, Birgersdotter-Green UM, Cha YM, Chung EH, Cronin EM, Curtis AB, Cygankiewicz I, Dandamudi G, Dubin AM, Ensch DP, Glotzer TV, Gold MR, Goldberger ZD, Gopinathannair R, Gorodeski EZ, Gutierrez A, Guzman JC, Huang W, Imrey PB, Indik JH, Karim S, Karpawich PP, Khaykin Y, Kiehl EL, Kron J, Kutyifa V, Link MS, Marine JE, Mullens W, Park SJ, Parkash R, Patete MF, Pathak RK, Perona CA, Rickard J, Schoenfeld MH, Seow SC, Shen WK, Shoda M, Singh JP, Slotwiner DJ, Sridhar ARM, Srivatsa UN, Stecker EC, Tanawuttiwat T, Tang WHW, Tapias CA, Tracy CM, Upadhyay GA, Varma N, Vernooy K, Vijayaraman P, Worsnick SA, Zareba W, Zeitler EP. 2023 HRS/APHRS/LAHRS guideline on cardiac physiologic pacing for the avoidance and mitigation of heart failure. Heart Rhythm 2023; 20:e17-e91. [PMID: 37283271 PMCID: PMC11062890 DOI: 10.1016/j.hrthm.2023.03.1538] [Citation(s) in RCA: 126] [Impact Index Per Article: 126.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 03/31/2023] [Indexed: 06/08/2023]
Abstract
Cardiac physiologic pacing (CPP), encompassing cardiac resynchronization therapy (CRT) and conduction system pacing (CSP), has emerged as a pacing therapy strategy that may mitigate or prevent the development of heart failure (HF) in patients with ventricular dyssynchrony or pacing-induced cardiomyopathy. This clinical practice guideline is intended to provide guidance on indications for CRT for HF therapy and CPP in patients with pacemaker indications or HF, patient selection, pre-procedure evaluation and preparation, implant procedure management, follow-up evaluation and optimization of CPP response, and use in pediatric populations. Gaps in knowledge, pointing to new directions for future research, are also identified.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Eugene H Chung
- University of Michigan Medical School, Ann Arbor, Michigan
| | | | | | | | | | - Anne M Dubin
- Stanford University, Pediatric Cardiology, Palo Alto, California
| | | | - Taya V Glotzer
- Hackensack Meridian School of Medicine, Hackensack, New Jersey
| | - Michael R Gold
- Medical University of South Carolina, Charleston, South Carolina
| | - Zachary D Goldberger
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | | | - Eiran Z Gorodeski
- University Hospitals and Case Western Reserve University School of Medicine, Cleveland, Ohio
| | | | | | - Weijian Huang
- First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Peter B Imrey
- Cleveland Clinic, Cleveland, Ohio; Case Western Reserve University, Cleveland, Ohio
| | - Julia H Indik
- University of Arizona, Sarver Heart Center, Tucson, Arizona
| | - Saima Karim
- MetroHealth Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Peter P Karpawich
- The Children's Hospital of Michigan, Central Michigan University, Detroit, Michigan
| | - Yaariv Khaykin
- Southlake Regional Health Center, Newmarket, Ontario, Canada
| | | | - Jordana Kron
- Virginia Commonwealth University, Richmond, Virginia
| | | | - Mark S Link
- University of Texas Southwestern Medical Center, Dallas, Texas
| | - Joseph E Marine
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Wilfried Mullens
- Ziekenhuis Oost-Limburg Genk, Belgium and Hasselt University, Hasselt, Belgium
| | - Seung-Jung Park
- Sungkyunkwan University School of Medicine, Samsung Medical Center, Seoul, Republic of Korea
| | - Ratika Parkash
- QEII Health Sciences Center, Halifax, Nova Scotia, Canada
| | | | - Rajeev Kumar Pathak
- Australian National University, Canberra Hospital, Garran, Australian Capital Territory, Australia
| | | | | | | | | | | | - Morio Shoda
- Tokyo Women's Medical University, Tokyo, Japan
| | - Jagmeet P Singh
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - David J Slotwiner
- Weill Cornell Medicine Population Health Sciences, New York, New York
| | | | | | | | | | | | | | - Cynthia M Tracy
- George Washington University, Washington, District of Columbia
| | | | | | - Kevin Vernooy
- Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, Maastricht, The Netherlands
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7
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Pujol-López M, Tolosana JM, Upadhyay GA, Mont L, Tung R. Left Bundle Branch Block: Characterization, Definitions, and Recent Insights into Conduction System Physiology. Cardiol Clin 2023; 41:379-391. [PMID: 37321688 DOI: 10.1016/j.ccl.2023.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
Left bundle branch block (LBBB) is not just a simple electrocardiogram alteration. The intricacies of this general terminology go beyond simple conduction block. This review puts together current knowledge on the historical concept of LBBB, clinical significance, and recent insights into the pathophysiology of human LBBB. LBBB is an entity that affects patient diagnosis (primary conduction disease, secondary to underlying pathology or iatrogenic), treatment (cardiac resynchronization therapy or conduction system pacing for heart failure), and prognosis. Recruiting the left bundle branch with conduction system pacing depends on the complex interaction between anatomy, site of pathophysiology, and delivery tools.
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Affiliation(s)
- Margarida Pujol-López
- Arrhythmia Section, Cardiology Department, Institut Clínic Cardiovascular, Hospital Clínic de Barcelona, Universitat de Barcelona, C/ Villarroel 170, Barcelona, Catalonia 08036, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Catalonia, Spain
| | - José M Tolosana
- Arrhythmia Section, Cardiology Department, Institut Clínic Cardiovascular, Hospital Clínic de Barcelona, Universitat de Barcelona, C/ Villarroel 170, Barcelona, Catalonia 08036, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Catalonia, Spain; Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares, Madrid, Spain
| | - Gaurav A Upadhyay
- Center for Arrhythmia Care, Pritzker School of Medicine, University of Chicago, The University of Chicago Medicine, Heart and Vascular Center, 5841 South Maryland Avenue, Chicago, IL 60637, USA
| | - Lluís Mont
- Arrhythmia Section, Cardiology Department, Institut Clínic Cardiovascular, Hospital Clínic de Barcelona, Universitat de Barcelona, C/ Villarroel 170, Barcelona, Catalonia 08036, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Catalonia, Spain; Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares, Madrid, Spain
| | - Roderick Tung
- Center for Arrhythmia Care, Pritzker School of Medicine, University of Chicago, The University of Chicago Medicine, Heart and Vascular Center, 5841 South Maryland Avenue, Chicago, IL 60637, USA.
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8
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Spitaler P, Pfeifer BE, Mayr A, Bachler R, Bilgeri V, Adukauskaite A, Bauer A, Stühlinger M, Barbieri F, Dichtl W. Visualization of the SyncAV ® Algorithm for CRT Optimization by Non-invasive Imaging of Cardiac Electrophysiology: NICE-CRT Trial. J Clin Med 2023; 12:4510. [PMID: 37445543 DOI: 10.3390/jcm12134510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 07/01/2023] [Accepted: 07/03/2023] [Indexed: 07/15/2023] Open
Abstract
(1) Background: Periodic repetitive AV interval optimization using a device-based algorithm in cardiac resynchronization therapy (CRT) devices may improve clinical outcomes. There is an unmet need to successfully transform its application into clinical routine. (2) Methods: Non-invasive imaging of cardiac electrophysiology was performed in different device programming settings of the SyncAV® algorithm in 14 heart failure patients with left bundle branch block and a PR interval ≤ 250 milliseconds to determine the shortest ventricular activation time. (3) Results: the best offset time (to be manually programmed) permitting automatic dynamic adjustment of the paced atrioventricular interval after every 256 heart beats was found to be 30 and 50 milliseconds, decreasing mean native QRS duration from 181.6 ± 23.9 milliseconds to 130.7 ± 10.0 and 130.1 ± 10.5 milliseconds, respectively (p = 0.01); this was followed by an offset of 40 milliseconds (decreasing QRS duration to 130.1 ± 12.2 milliseconds; p = 0.08). (4) Conclusions: The herein presented NICE-CRT study supports the current recommendation to program an offset of 50 milliseconds as default in patients with left bundle branch block and preserved atrioventricular conduction after implantation of a CRT device capable of SyncAV® optimization. Alternatively, offset programming of 30 milliseconds may also be applied as default programming. In patients with no or poor CRT response, additional efforts should be spent to individualize best offset programming with electrocardiographic optimization techniques.
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Affiliation(s)
- Philipp Spitaler
- Department of Internal Medicine III, Medical University of Innsbruck, 6020 Innsbruck, Austria
| | - Bernhard Erich Pfeifer
- Institute of Clinical Epidemiology, Tirol Kliniken, 6020 Innsbruck, Austria
- Institute of Medical Informatics, UMIT TIROL, Eduart Wallnöfer Zentrum, 6600 Hall in Tirol, Austria
| | - Agnes Mayr
- Department of Radiology, Medical University Innsbruck, 6020 Innsbruck, Austria
| | | | - Valentin Bilgeri
- Department of Internal Medicine III, Medical University of Innsbruck, 6020 Innsbruck, Austria
| | - Agne Adukauskaite
- Department of Internal Medicine III, Medical University of Innsbruck, 6020 Innsbruck, Austria
| | - Axel Bauer
- Department of Internal Medicine III, Medical University of Innsbruck, 6020 Innsbruck, Austria
| | - Markus Stühlinger
- Department of Internal Medicine III, Medical University of Innsbruck, 6020 Innsbruck, Austria
| | - Fabian Barbieri
- Department of Internal Medicine III, Medical University of Innsbruck, 6020 Innsbruck, Austria
- Deutsches Herzzentrum der Charité, Department of Cardiology, Angiology and Intensive Care Medicine, Hindenburgdamm 30, 12203 Berlin, Germany
| | - Wolfgang Dichtl
- Department of Internal Medicine III, Medical University of Innsbruck, 6020 Innsbruck, Austria
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9
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Pujol-López M, Ferró E, Borràs R, Garre P, Guasch E, Jiménez-Arjona R, Garcia-Ribas C, Doltra A, Niebla M, Carro E, Roca-Luque I, Guichard JB, Puente JL, Uribe L, Vázquez-Calvo S, Castel MÁ, Arbelo E, Porta-Sánchez A, Sitges M, Tolosana JM, Mont L. Stepwise application of ECG and electrogram-based criteria to ensure electrical resynchronization with left bundle branch pacing. Europace 2023; 25:euad128. [PMID: 37294671 PMCID: PMC10254073 DOI: 10.1093/europace/euad128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 04/13/2023] [Indexed: 06/11/2023] Open
Abstract
AIMS To define a stepwise application of left bundle branch pacing (LBBP) criteria that will simplify implantation and guarantee electrical resynchronization. Left bundle branch pacing has emerged as an alternative to biventricular pacing. However, a systematic stepwise criterion to ensure electrical resynchronization is lacking. METHODS AND RESULTS A cohort of 24 patients from the LEVEL-AT trial (NCT04054895) who received LBBP and had electrocardiographic imaging (ECGI) at 45 days post-implant were included. The usefulness of ECG- and electrogram-based criteria to predict accurate electrical resynchronization with LBBP were analyzed. A two-step approach was developed. The gold standard used to confirm resynchronization was the change in ventricular activation pattern and shortening in left ventricular activation time, assessed by ECGI. Twenty-two (91.6%) patients showed electrical resynchronization on ECGI. All patients fulfilled pre-screwing requisites: lead in septal position in left-oblique projection and W paced morphology in V1. In the first step, presence of either right bundle branch conduction delay pattern (qR or rSR in V1) or left bundle branch capture Plus (QRS ≤120 ms) resulted in 95% sensitivity and 100% specificity to predict LBBP resynchronization, with an accuracy of 95.8%. In the second step, the presence of selective capture (100% specificity, only 41% sensitivity) or a spike-R <80 ms in non-selective capture (100% specificity, sensitivity 46%) ensured 100% accuracy to predict resynchronization with LBBP. CONCLUSION Stepwise application of ECG and electrogram criteria may provide an accurate assessment of electrical resynchronization with LBBP (Graphical abstract).
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Affiliation(s)
- Margarida Pujol-López
- Institut Clínic Cardiovascular (ICCV), Hospital Clínic, Universitat de Barcelona, C/Villarroel 170, 08036 Catalonia, Spain
- Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia, Spain
| | - Elisenda Ferró
- Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia, Spain
| | - Roger Borràs
- Institut Clínic Cardiovascular (ICCV), Hospital Clínic, Universitat de Barcelona, C/Villarroel 170, 08036 Catalonia, Spain
- Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia, Spain
| | - Paz Garre
- Institut Clínic Cardiovascular (ICCV), Hospital Clínic, Universitat de Barcelona, C/Villarroel 170, 08036 Catalonia, Spain
| | - Eduard Guasch
- Institut Clínic Cardiovascular (ICCV), Hospital Clínic, Universitat de Barcelona, C/Villarroel 170, 08036 Catalonia, Spain
- Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia, Spain
- Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - Rafael Jiménez-Arjona
- Institut Clínic Cardiovascular (ICCV), Hospital Clínic, Universitat de Barcelona, C/Villarroel 170, 08036 Catalonia, Spain
| | - Cora Garcia-Ribas
- Institut Clínic Cardiovascular (ICCV), Hospital Clínic, Universitat de Barcelona, C/Villarroel 170, 08036 Catalonia, Spain
| | - Adelina Doltra
- Institut Clínic Cardiovascular (ICCV), Hospital Clínic, Universitat de Barcelona, C/Villarroel 170, 08036 Catalonia, Spain
- Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia, Spain
| | - Mireia Niebla
- Institut Clínic Cardiovascular (ICCV), Hospital Clínic, Universitat de Barcelona, C/Villarroel 170, 08036 Catalonia, Spain
- Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia, Spain
| | - Esther Carro
- Institut Clínic Cardiovascular (ICCV), Hospital Clínic, Universitat de Barcelona, C/Villarroel 170, 08036 Catalonia, Spain
| | - Ivo Roca-Luque
- Institut Clínic Cardiovascular (ICCV), Hospital Clínic, Universitat de Barcelona, C/Villarroel 170, 08036 Catalonia, Spain
- Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia, Spain
- Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - J Baptiste Guichard
- Institut Clínic Cardiovascular (ICCV), Hospital Clínic, Universitat de Barcelona, C/Villarroel 170, 08036 Catalonia, Spain
- Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - J Luis Puente
- Institut Clínic Cardiovascular (ICCV), Hospital Clínic, Universitat de Barcelona, C/Villarroel 170, 08036 Catalonia, Spain
| | - Laura Uribe
- Institut Clínic Cardiovascular (ICCV), Hospital Clínic, Universitat de Barcelona, C/Villarroel 170, 08036 Catalonia, Spain
| | - Sara Vázquez-Calvo
- Institut Clínic Cardiovascular (ICCV), Hospital Clínic, Universitat de Barcelona, C/Villarroel 170, 08036 Catalonia, Spain
- Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia, Spain
| | - M Ángeles Castel
- Institut Clínic Cardiovascular (ICCV), Hospital Clínic, Universitat de Barcelona, C/Villarroel 170, 08036 Catalonia, Spain
- Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia, Spain
- Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - Elena Arbelo
- Institut Clínic Cardiovascular (ICCV), Hospital Clínic, Universitat de Barcelona, C/Villarroel 170, 08036 Catalonia, Spain
- Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia, Spain
- Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - Andreu Porta-Sánchez
- Institut Clínic Cardiovascular (ICCV), Hospital Clínic, Universitat de Barcelona, C/Villarroel 170, 08036 Catalonia, Spain
| | - Marta Sitges
- Institut Clínic Cardiovascular (ICCV), Hospital Clínic, Universitat de Barcelona, C/Villarroel 170, 08036 Catalonia, Spain
- Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia, Spain
- Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - José M Tolosana
- Institut Clínic Cardiovascular (ICCV), Hospital Clínic, Universitat de Barcelona, C/Villarroel 170, 08036 Catalonia, Spain
- Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia, Spain
- Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - Lluís Mont
- Institut Clínic Cardiovascular (ICCV), Hospital Clínic, Universitat de Barcelona, C/Villarroel 170, 08036 Catalonia, Spain
- Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia, Spain
- Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
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10
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Guillem MS, Pujol-López M, Sanchez-Arciniegas J, Mont L. In silico experiments explain the non-consistent benefit of conduction system pacing over cardiac resynchronization therapy. The need to personalize therapy. J Cardiovasc Electrophysiol 2023; 34:994-996. [PMID: 36852911 DOI: 10.1111/jce.15871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Accepted: 02/20/2023] [Indexed: 03/01/2023]
Affiliation(s)
- María S Guillem
- ITACA Institute, Universitat Politècnica de València, Valencia, Spain
| | - Margarida Pujol-López
- Secció d'Arrítmies, Institut Clínic Cardiovascular, Hospital Clínic de Barcelona, Barcelona, Catalonia, Spain.,Institut de Recerca Biomèdica August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia, Spain
| | | | - Lluís Mont
- Secció d'Arrítmies, Institut Clínic Cardiovascular, Hospital Clínic de Barcelona, Barcelona, Catalonia, Spain.,Institut de Recerca Biomèdica August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia, Spain.,Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
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11
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Pujol-Lopez M, Jiménez-Arjona R, Garre P, Guasch E, Borràs R, Doltra A, Ferró E, García-Ribas C, Niebla M, Carro E, Puente JL, Vázquez-Calvo S, Invers-Rubio E, Roca-Luque I, Castel MÁ, Arbelo E, Sitges M, Brugada J, Tolosana JM, Mont L. Conduction System Pacing vs Biventricular Pacing in Heart Failure and Wide QRS Patients: LEVEL-AT Trial. JACC Clin Electrophysiol 2022; 8:1431-1445. [PMID: 36424012 DOI: 10.1016/j.jacep.2022.08.001] [Citation(s) in RCA: 37] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 07/07/2022] [Accepted: 08/01/2022] [Indexed: 11/05/2022]
Abstract
BACKGROUND Conduction system pacing (CSP) has emerged as an alternative to biventricular pacing (BiVP). Randomized studies comparing both therapies are scarce and do not include left bundle branch pacing. OBJECTIVES This study aims to compare ventricular resynchronization achieved by CSP vs BiVP in patients with cardiac resynchronization therapy indication. METHODS LEVEL-AT (Left Ventricular Activation Time Shortening with Conduction System Pacing vs Biventricular Resynchronization Therapy) was a randomized, parallel, controlled, noninferiority trial. Seventy patients with cardiac resynchronization therapy indication were randomized 1:1 to BiVP or CSP, and followed up for 6 months. Crossover was allowed when primary allocation procedure failed. Primary endpoint was the change in left ventricular activation time, measured using electrocardiographic imaging. Secondary endpoints were left ventricular reverse remodeling and the combined endpoint of heart failure hospitalization or death at 6-month follow-up. RESULTS Thirty-five patients were allocated to each group. Eight (23%) patients crossed over from CSP to BiVP; 2 patients (6%) crossed over from BiVP to CSP. Electrocardiographic imaging could not be performed in 2 patients in each group. A similar decrease in left ventricular activation time was achieved by CSP and BiVP (-28 ± 26 ms vs -21 ± 20 ms, respectively; mean difference -6.8 ms; 95% CI: -18.3 ms to 4.6 ms; P < 0.001 for noninferiority). Both groups showed a similar change in left ventricular end-systolic volume (-37 ± 59 mL CSP vs -30 ± 41 mL BiVP; mean difference: -8 mL; 95% CI: -33 mL to 17 mL; P = 0.04 for noninferiority) and similar rates of mortality or heart failure hospitalizations (2.9% vs 11.4%, respectively) (P = 0.002 for noninferiority). CONCLUSIONS Similar degrees of cardiac resynchronization, ventricular reverse remodeling, and clinical outcomes were attained by CSP as compared to BiVP. CSP could be a feasible alternative to BiVP. (LEVEL-AT [Left Ventricular Activation Time Shortening With Conduction System Pacing vs Biventricular Resynchronization Therapy]; NCT04054895).
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Affiliation(s)
- Margarida Pujol-Lopez
- Institut Clínic Cardiovascular (ICCV), Hospital Clínic, Universitat de Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia, Spain.
| | - Rafael Jiménez-Arjona
- Institut Clínic Cardiovascular (ICCV), Hospital Clínic, Universitat de Barcelona, Catalonia, Spain
| | - Paz Garre
- Institut Clínic Cardiovascular (ICCV), Hospital Clínic, Universitat de Barcelona, Catalonia, Spain
| | - Eduard Guasch
- Institut Clínic Cardiovascular (ICCV), Hospital Clínic, Universitat de Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia, Spain; Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - Roger Borràs
- Institut Clínic Cardiovascular (ICCV), Hospital Clínic, Universitat de Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia, Spain; Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Instituto de Salud Carlos III, Madrid, Spain
| | - Adelina Doltra
- Institut Clínic Cardiovascular (ICCV), Hospital Clínic, Universitat de Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia, Spain
| | - Elisenda Ferró
- Medtronic Ibérica, Barcelona, Spain; Fundació Clínic per a la Recerca Biomèdica (FCRB), Barcelona, Catalonia, Spain
| | - Cora García-Ribas
- Institut Clínic Cardiovascular (ICCV), Hospital Clínic, Universitat de Barcelona, Catalonia, Spain; Fundació Clínic per a la Recerca Biomèdica (FCRB), Barcelona, Catalonia, Spain
| | - Mireia Niebla
- Institut Clínic Cardiovascular (ICCV), Hospital Clínic, Universitat de Barcelona, Catalonia, Spain
| | - Esther Carro
- Institut Clínic Cardiovascular (ICCV), Hospital Clínic, Universitat de Barcelona, Catalonia, Spain
| | - Jose L Puente
- Institut Clínic Cardiovascular (ICCV), Hospital Clínic, Universitat de Barcelona, Catalonia, Spain
| | - Sara Vázquez-Calvo
- Institut Clínic Cardiovascular (ICCV), Hospital Clínic, Universitat de Barcelona, Catalonia, Spain
| | - Eric Invers-Rubio
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia, Spain
| | - Ivo Roca-Luque
- Institut Clínic Cardiovascular (ICCV), Hospital Clínic, Universitat de Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia, Spain; Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - M Ángeles Castel
- Institut Clínic Cardiovascular (ICCV), Hospital Clínic, Universitat de Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia, Spain; Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - Elena Arbelo
- Institut Clínic Cardiovascular (ICCV), Hospital Clínic, Universitat de Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia, Spain; Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - Marta Sitges
- Institut Clínic Cardiovascular (ICCV), Hospital Clínic, Universitat de Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia, Spain; Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - Josep Brugada
- Institut Clínic Cardiovascular (ICCV), Hospital Clínic, Universitat de Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia, Spain; Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - José M Tolosana
- Institut Clínic Cardiovascular (ICCV), Hospital Clínic, Universitat de Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia, Spain; Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain.
| | - Lluís Mont
- Institut Clínic Cardiovascular (ICCV), Hospital Clínic, Universitat de Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia, Spain; Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
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12
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Green PG, Herring N, Betts TR. What Have We Learned in the Last 20 Years About CRT Non-Responders? Card Electrophysiol Clin 2022; 14:283-296. [PMID: 35715086 DOI: 10.1016/j.ccep.2021.12.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Although cardiac resynchronization therapy (CRT) has become well established in the treatment of heart failure, the management of patients who do not respond after CRT remains a key challenge. This review will summarize what we have learned about non-responders over the last 20 years and discuss methods for optimizing response, including the introduction of novel therapies.
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Affiliation(s)
- Peregrine G Green
- Department of Physiology, Anatomy and Genetics, University of Oxford, Sherrington Building, Parks Road, Oxford, OX1 3PT, UK; Oxford Centre for Clinical Magnetic Resonance Research (OCMR), University of Oxford, Level 0 John Radcliffe Hospital, Oxford, OX3 9DU, UK; Oxford Heart Centre, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, OX3 9DU, UK
| | - Neil Herring
- Department of Physiology, Anatomy and Genetics, University of Oxford, Sherrington Building, Parks Road, Oxford, OX1 3PT, UK; Oxford Heart Centre, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, OX3 9DU, UK
| | - Timothy R Betts
- Oxford Heart Centre, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, OX3 9DU, UK; Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.
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13
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Programming Algorithms for Cardiac Resynchronization Therapy. Card Electrophysiol Clin 2022; 14:243-252. [PMID: 35715082 DOI: 10.1016/j.ccep.2021.12.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Current cardiac resynchronization therapy (CRT) implant guidelines emphasize the presence of electrical dyssynchrony (left bundle branch block (LBBB) and QRS > 150 ms) yet have modest predictive value for response and have not reduced the 30% nonresponse rate. Optimized programming to optimize CRT delivery has promised much but to date has largely been ineffective. What is missing is the understanding of LV paced effects (which are unpredictable) and optimal paced AV interval (that can be conserved during physiologic variations) that then can be incorporated into an individualized programming prescription. Automatic device-based algorithms that deliver electrical optimization and maintain this during ambulatory fluctuations in AV interval are discussed.
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14
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Zweerink A, Burri H. His-Optimized and Left Bundle Branch-Optimized Cardiac Resynchronization Therapy: In Control of Fusion Pacing. Card Electrophysiol Clin 2022; 14:311-321. [PMID: 35715088 DOI: 10.1016/j.ccep.2021.12.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Fusion pacing, which exploits conduction via the intrinsic His-Purkinje system, forms the basis of recent cardiac resynchronization therapy (CRT) optimization algorithms. However, settings need to be constantly adjusted to accommodate for changes in AV conduction, and the algorithms are not always available (eg, depending on the device, in case of AV block or with atrial fibrillation). His-optimized cardiac resynchronization therapy (HOT-CRT), and left-bundle branch optimized cardiac resynchronization therapy (LOT-CRT) which combines conduction system pacing with ventricular fusion pacing, provide constant fusion with ventricular activation (irrespective of intrinsic AV conduction). These modalities provide promising treatment strategies for patients with heart failure, especially in those with chronic atrial fibrillation who require CRT (in whom the atrial port is usually plugged and can be used to connect the conduction system pacing lead).
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Affiliation(s)
- Alwin Zweerink
- Department of Cardiology, University Hospital of Geneva, Geneva, Switzerland; Department of Cardiology and Amsterdam Cardiovascular Sciences (ACS), Amsterdam University Medical Centers (AUMC), Location VU Medical Center, Amsterdam, The Netherlands
| | - Haran Burri
- Department of Cardiology, University Hospital of Geneva, Geneva, Switzerland.
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15
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Vacarescu C, Luca CT, Feier H, Gaiță D, Crișan S, Negru AG, Iurciuc S, Goanță EV, Mornos C, Lazăr MA, Streian CG, Arnăutu DA, Turi VR, Cozma D. Betablockers and Ivabradine Titration According to Exercise Test in LV Only Fusion CRT Pacing. Diagnostics (Basel) 2022; 12:1096. [PMID: 35626251 PMCID: PMC9139204 DOI: 10.3390/diagnostics12051096] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Revised: 04/17/2022] [Accepted: 04/26/2022] [Indexed: 11/17/2022] Open
Abstract
Background: Betablockers (BB)/ivabradine titration in fusion CRT pacing (CRTP) is understudied. Aim: To assess drug optimization using systematic exercise tests (ET) in fusion CRTP with preserved atrioventricular conduction (AVc). Methods: Changes in drug management were assessed during systematic follow-ups in CRTP patients without right ventricle lead. Shorter AVc (PR interval) allowed BB up-titration, while longer AVc needed BB down-titration, favoring ivabradine. Constant fusion pacing was the goal to improve outcomes. Results: 64 patients, 62.5 ± 9.5 y.o divided into three groups: shorter PR (<160 ms), normal (160−200 ms), longer (200−240 ms); follow-up 59 ± 26 months. Drugs were titrated in case of: capture loss due to AVc shortening (14%), AVc lengthening (5%), chronotropic incompetence (11%), maximum tracking rate issues (9%), brady/tachyarrhythmias (8%). Interventions: BB up-titration (78% shorter PR, 19% normal PR, 5% longer PR), BB down-titration (22% shorter PR, 14% normal PR), BB exclusion (16% longer PR), adding/up-titration ivabradine (22% shorter PR, 19% normal PR, 5% longer PR), ivabradine down-titration (22% shorter PR, 3% normal PR), ivabradine exclusion (11% normal PR, 5% longer PR). Drug strategy was changed in 165 follow-ups from 371 recorded (42% patients). Conclusions: BBs/ivabradine titration and routine ET during follow-ups in patients with fusion CRTP should be a standard approach to maximize resynchronization response. Fusion CRTP showed a positive outcome with important LV reverse remodeling and significant LVEF improvement in carefully selected patients.
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Affiliation(s)
- Cristina Vacarescu
- Cardiology Department, “Victor Babes” University of Medicine and Pharmacy, 2 Eftimie Murgu Sq., 300041 Timisoara, Romania; (C.V.); (H.F.); (D.G.); (A.-G.N.); (S.I.); (E.-V.G.); (C.M.); (M.-A.L.); (C.-G.S.); (D.-A.A.); (V.-R.T.); (D.C.)
- Institute of Cardiovascular Diseases Timisoara, 13A Gheorghe Adam Street, 300310 Timisoara, Romania
- Research Center of the Institute of Cardiovascular Diseases Timisoara, 13A Gheorghe Adam Street, 300310 Timisoara, Romania
| | - Constantin-Tudor Luca
- Cardiology Department, “Victor Babes” University of Medicine and Pharmacy, 2 Eftimie Murgu Sq., 300041 Timisoara, Romania; (C.V.); (H.F.); (D.G.); (A.-G.N.); (S.I.); (E.-V.G.); (C.M.); (M.-A.L.); (C.-G.S.); (D.-A.A.); (V.-R.T.); (D.C.)
- Institute of Cardiovascular Diseases Timisoara, 13A Gheorghe Adam Street, 300310 Timisoara, Romania
- Research Center of the Institute of Cardiovascular Diseases Timisoara, 13A Gheorghe Adam Street, 300310 Timisoara, Romania
| | - Horea Feier
- Cardiology Department, “Victor Babes” University of Medicine and Pharmacy, 2 Eftimie Murgu Sq., 300041 Timisoara, Romania; (C.V.); (H.F.); (D.G.); (A.-G.N.); (S.I.); (E.-V.G.); (C.M.); (M.-A.L.); (C.-G.S.); (D.-A.A.); (V.-R.T.); (D.C.)
- Institute of Cardiovascular Diseases Timisoara, 13A Gheorghe Adam Street, 300310 Timisoara, Romania
- Research Center of the Institute of Cardiovascular Diseases Timisoara, 13A Gheorghe Adam Street, 300310 Timisoara, Romania
| | - Dan Gaiță
- Cardiology Department, “Victor Babes” University of Medicine and Pharmacy, 2 Eftimie Murgu Sq., 300041 Timisoara, Romania; (C.V.); (H.F.); (D.G.); (A.-G.N.); (S.I.); (E.-V.G.); (C.M.); (M.-A.L.); (C.-G.S.); (D.-A.A.); (V.-R.T.); (D.C.)
- Institute of Cardiovascular Diseases Timisoara, 13A Gheorghe Adam Street, 300310 Timisoara, Romania
- Research Center of the Institute of Cardiovascular Diseases Timisoara, 13A Gheorghe Adam Street, 300310 Timisoara, Romania
| | - Simina Crișan
- Cardiology Department, “Victor Babes” University of Medicine and Pharmacy, 2 Eftimie Murgu Sq., 300041 Timisoara, Romania; (C.V.); (H.F.); (D.G.); (A.-G.N.); (S.I.); (E.-V.G.); (C.M.); (M.-A.L.); (C.-G.S.); (D.-A.A.); (V.-R.T.); (D.C.)
- Institute of Cardiovascular Diseases Timisoara, 13A Gheorghe Adam Street, 300310 Timisoara, Romania
- Research Center of the Institute of Cardiovascular Diseases Timisoara, 13A Gheorghe Adam Street, 300310 Timisoara, Romania
| | - Alina-Gabriela Negru
- Cardiology Department, “Victor Babes” University of Medicine and Pharmacy, 2 Eftimie Murgu Sq., 300041 Timisoara, Romania; (C.V.); (H.F.); (D.G.); (A.-G.N.); (S.I.); (E.-V.G.); (C.M.); (M.-A.L.); (C.-G.S.); (D.-A.A.); (V.-R.T.); (D.C.)
- Institute of Cardiovascular Diseases Timisoara, 13A Gheorghe Adam Street, 300310 Timisoara, Romania
- Research Center of the Institute of Cardiovascular Diseases Timisoara, 13A Gheorghe Adam Street, 300310 Timisoara, Romania
| | - Stela Iurciuc
- Cardiology Department, “Victor Babes” University of Medicine and Pharmacy, 2 Eftimie Murgu Sq., 300041 Timisoara, Romania; (C.V.); (H.F.); (D.G.); (A.-G.N.); (S.I.); (E.-V.G.); (C.M.); (M.-A.L.); (C.-G.S.); (D.-A.A.); (V.-R.T.); (D.C.)
| | - Emilia-Violeta Goanță
- Cardiology Department, “Victor Babes” University of Medicine and Pharmacy, 2 Eftimie Murgu Sq., 300041 Timisoara, Romania; (C.V.); (H.F.); (D.G.); (A.-G.N.); (S.I.); (E.-V.G.); (C.M.); (M.-A.L.); (C.-G.S.); (D.-A.A.); (V.-R.T.); (D.C.)
- Research Center of the Institute of Cardiovascular Diseases Timisoara, 13A Gheorghe Adam Street, 300310 Timisoara, Romania
| | - Cristian Mornos
- Cardiology Department, “Victor Babes” University of Medicine and Pharmacy, 2 Eftimie Murgu Sq., 300041 Timisoara, Romania; (C.V.); (H.F.); (D.G.); (A.-G.N.); (S.I.); (E.-V.G.); (C.M.); (M.-A.L.); (C.-G.S.); (D.-A.A.); (V.-R.T.); (D.C.)
- Institute of Cardiovascular Diseases Timisoara, 13A Gheorghe Adam Street, 300310 Timisoara, Romania
- Research Center of the Institute of Cardiovascular Diseases Timisoara, 13A Gheorghe Adam Street, 300310 Timisoara, Romania
| | - Mihai-Andrei Lazăr
- Cardiology Department, “Victor Babes” University of Medicine and Pharmacy, 2 Eftimie Murgu Sq., 300041 Timisoara, Romania; (C.V.); (H.F.); (D.G.); (A.-G.N.); (S.I.); (E.-V.G.); (C.M.); (M.-A.L.); (C.-G.S.); (D.-A.A.); (V.-R.T.); (D.C.)
- Institute of Cardiovascular Diseases Timisoara, 13A Gheorghe Adam Street, 300310 Timisoara, Romania
- Research Center of the Institute of Cardiovascular Diseases Timisoara, 13A Gheorghe Adam Street, 300310 Timisoara, Romania
| | - Caius-Glad Streian
- Cardiology Department, “Victor Babes” University of Medicine and Pharmacy, 2 Eftimie Murgu Sq., 300041 Timisoara, Romania; (C.V.); (H.F.); (D.G.); (A.-G.N.); (S.I.); (E.-V.G.); (C.M.); (M.-A.L.); (C.-G.S.); (D.-A.A.); (V.-R.T.); (D.C.)
- Institute of Cardiovascular Diseases Timisoara, 13A Gheorghe Adam Street, 300310 Timisoara, Romania
- Research Center of the Institute of Cardiovascular Diseases Timisoara, 13A Gheorghe Adam Street, 300310 Timisoara, Romania
| | - Diana-Aurora Arnăutu
- Cardiology Department, “Victor Babes” University of Medicine and Pharmacy, 2 Eftimie Murgu Sq., 300041 Timisoara, Romania; (C.V.); (H.F.); (D.G.); (A.-G.N.); (S.I.); (E.-V.G.); (C.M.); (M.-A.L.); (C.-G.S.); (D.-A.A.); (V.-R.T.); (D.C.)
| | - Vladiana-Romina Turi
- Cardiology Department, “Victor Babes” University of Medicine and Pharmacy, 2 Eftimie Murgu Sq., 300041 Timisoara, Romania; (C.V.); (H.F.); (D.G.); (A.-G.N.); (S.I.); (E.-V.G.); (C.M.); (M.-A.L.); (C.-G.S.); (D.-A.A.); (V.-R.T.); (D.C.)
- Research Center of the Institute of Cardiovascular Diseases Timisoara, 13A Gheorghe Adam Street, 300310 Timisoara, Romania
| | - Dragos Cozma
- Cardiology Department, “Victor Babes” University of Medicine and Pharmacy, 2 Eftimie Murgu Sq., 300041 Timisoara, Romania; (C.V.); (H.F.); (D.G.); (A.-G.N.); (S.I.); (E.-V.G.); (C.M.); (M.-A.L.); (C.-G.S.); (D.-A.A.); (V.-R.T.); (D.C.)
- Institute of Cardiovascular Diseases Timisoara, 13A Gheorghe Adam Street, 300310 Timisoara, Romania
- Research Center of the Institute of Cardiovascular Diseases Timisoara, 13A Gheorghe Adam Street, 300310 Timisoara, Romania
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16
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Pujol-López M, Jiménez Arjona R, Guasch E, Doltra A, Borràs R, Roca Luque I, Castel MÁ, Garre P, Ferró E, Niebla M, Carro E, Arbelo E, Sitges M, Tolosana JM, Mont L. Septal Flash Correction with His-Purkinje Pacing Predicts Echocardiographic Response in Resynchronization Therapy. Pacing Clin Electrophysiol 2022; 45:374-383. [PMID: 35015308 PMCID: PMC9303224 DOI: 10.1111/pace.14445] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Revised: 12/27/2021] [Accepted: 01/02/2022] [Indexed: 11/26/2022]
Abstract
Background His‐Purkinje conduction system pacing (HPCSP) has been proposed as an alternative to Cardiac Resynchronization Therapy (CRT); however, predictors of echocardiographic response have not been described in this population. Septal flash (SF), a fast contraction and relaxation of the septum, is a marker of intraventricular dyssynchrony. Methods The study aimed to analyze whether HPCSP corrects SF in patients with CRT indication, and if correction of SF predicts echocardiographic response. This retrospective analysis of prospectively collected data included 30 patients. Left ventricular ejection fraction (LVEF) was measured with echocardiography at baseline and at 6‐month follow‐up. Echocardiographic response was defined as increase in five points in LVEF. Results HPCSP shortened QRS duration by 48 ± 21 ms and SF was significantly decreased (baseline 3.6 ± 2.2 mm vs. HPCSP 1.5 ± 1.5 mm p < .0001). At 6‐month follow‐up, mean LVEF improvement was 8.6% ± 8.7% and 64% of patients were responders. There was a significant correlation between SF correction and increased LVEF (r = .61, p = .004). A correction of ≥1.5 mm (baseline SF – paced SF) had a sensitivity of 81% and 80% specificity to predict echocardiographic response (area under the curve 0.856, p = .019). Conclusion HPCSP improves intraventricular dyssynchrony and results in 64% echocardiographic responders at 6‐month follow‐up. Dyssynchrony improvement with SF correction may predict echocardiographic response at 6‐month follow‐up.
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Affiliation(s)
- Margarida Pujol-López
- Institut Clínic Cardiovascular (ICCV), Hospital Clínic, Universitat de Barcelona, Catalonia, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia, Spain
| | - Rafael Jiménez Arjona
- Institut Clínic Cardiovascular (ICCV), Hospital Clínic, Universitat de Barcelona, Catalonia, Spain
| | - Eduard Guasch
- Institut Clínic Cardiovascular (ICCV), Hospital Clínic, Universitat de Barcelona, Catalonia, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia, Spain.,Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - Adelina Doltra
- Institut Clínic Cardiovascular (ICCV), Hospital Clínic, Universitat de Barcelona, Catalonia, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia, Spain
| | - Roger Borràs
- Institut Clínic Cardiovascular (ICCV), Hospital Clínic, Universitat de Barcelona, Catalonia, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia, Spain
| | - Ivo Roca Luque
- Institut Clínic Cardiovascular (ICCV), Hospital Clínic, Universitat de Barcelona, Catalonia, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia, Spain
| | - M Ángeles Castel
- Institut Clínic Cardiovascular (ICCV), Hospital Clínic, Universitat de Barcelona, Catalonia, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia, Spain.,Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - Paz Garre
- Institut Clínic Cardiovascular (ICCV), Hospital Clínic, Universitat de Barcelona, Catalonia, Spain
| | - Elisenda Ferró
- Medtronic Iberica, Madrid, Spain.,Fundació Clínic per a la Recerca Biomèdica (FCRB), Barcelona, Catalonia, Spain
| | - Mireia Niebla
- Institut Clínic Cardiovascular (ICCV), Hospital Clínic, Universitat de Barcelona, Catalonia, Spain
| | - Esther Carro
- Institut Clínic Cardiovascular (ICCV), Hospital Clínic, Universitat de Barcelona, Catalonia, Spain
| | - Elena Arbelo
- Institut Clínic Cardiovascular (ICCV), Hospital Clínic, Universitat de Barcelona, Catalonia, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia, Spain.,Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - Marta Sitges
- Institut Clínic Cardiovascular (ICCV), Hospital Clínic, Universitat de Barcelona, Catalonia, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia, Spain.,Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - José M Tolosana
- Institut Clínic Cardiovascular (ICCV), Hospital Clínic, Universitat de Barcelona, Catalonia, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia, Spain.,Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - Lluís Mont
- Institut Clínic Cardiovascular (ICCV), Hospital Clínic, Universitat de Barcelona, Catalonia, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia, Spain.,Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
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17
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Waddingham PH, Mangual J, Orini M, Badie N, McSpadden L, Lambiase PD, Chow AW. Noninvasive electrocardiographic imaging of dynamic atrioventricular delay programming in a patient with left bundle branch block. HeartRhythm Case Rep 2021; 7:849-853. [PMID: 34987974 PMCID: PMC8695252 DOI: 10.1016/j.hrcr.2021.09.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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18
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Left Bundle Branch Block: Characterization, Definitions, and Recent Insights into Conduction System Physiology. Card Electrophysiol Clin 2021; 13:671-684. [PMID: 34689894 DOI: 10.1016/j.ccep.2021.07.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Left bundle branch block (LBBB) is not just a simple electrocardiogram alteration. The intricacies of this general terminology go beyond simple conduction block. This review puts together current knowledge on the historical concept of LBBB, clinical significance, and recent insights into the pathophysiology of human LBBB. LBBB is an entity that affects patient diagnosis (primary conduction disease, secondary to underlying pathology or iatrogenic), treatment (cardiac resynchronization therapy or conduction system pacing for heart failure), and prognosis. Recruiting the left bundle branch with conduction system pacing depends on the complex interaction between anatomy, site of pathophysiology, and delivery tools.
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19
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Manolis AS, Manolis AA, Manolis TA, Melita H. Electrocardiography of cardiac resynchronization therapy: Pitfalls and practical tips. J Cardiovasc Electrophysiol 2021; 32:3228-3244. [PMID: 34664758 DOI: 10.1111/jce.15267] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 09/11/2021] [Accepted: 09/29/2021] [Indexed: 12/25/2022]
Abstract
Cardiac resynchronization therapy (CRT) has been established as an effective mode of therapy in patients with heart failure and concurrent cardiac dyssynchrony, principally in the form of left bundle branch block (LBBB). The widespread use of CRT has ushered in a new landscape in 12-lead electrocardiography (ECG). ECG readings in these patients are most important to guide troubleshooting and also appropriate device programming, as well as discerning and managing nonresponders. A set of four ECG recordings need to accompany each patient with a CRT device, including a baseline ECG and recordings from monochamber (right and left ventricular) and biventricular pacing, which can be compared against a new recording to facilitate the evaluation of proper versus problematic biventricular pacing. Precordial ECG leads V1/2 acquired at the fourth intercostal space and limb leads, I and III, together with a quick assessment of perpendicular leads I and aVF to determine the quadrant of the QRS axis in the hexaxial diagram, may provide the framework for proper ECG interpretation in these patients. This important issue of 12-lead ECG in CRT patients is herein reviewed, pitfalls are pointed out and practical tips are provided for ECG reading to help recognize and manage problems with CRT device function. Furthermore, several pertinent ECG recordings and tabulated data are provided, and an algorithm is suggested that integrates prior algorithms and relevant information from current literature.
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Affiliation(s)
- Antonis S Manolis
- First Department of Cardiology, Athens University School of Medicine, Athens, Greece
| | | | | | - Helen Melita
- Central Laboratories, Onassis Cardiac Surgery Center, Athens, Greece
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20
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Wang Z, Li P, Zhang B, Huang J, Chen S, Cai Z, Qin Y, Fan J, Tang W, Qin Y, Li R, Zhao X. Improvement of LV Reverse Remodeling Using Dynamic Programming of Fusion-Optimized Atrioventricular Intervals in Cardiac Resynchronization Therapy. Front Cardiovasc Med 2021; 8:700424. [PMID: 34490369 PMCID: PMC8417774 DOI: 10.3389/fcvm.2021.700424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 07/20/2021] [Indexed: 12/04/2022] Open
Abstract
Background: The patient-tailored SyncAV algorithm shortens the QRS duration (QRSd) beyond what conventional biventricular (BiV) pacing can. However, evidence of the ability of SyncAV to improve the cardiac resynchronization therapy (CRT) response is lacking. The aim of this study was to evaluate the impact of CRT enhanced by SyncAV on echocardiographic and clinical responses. Methods and Results: Consecutive heart failure (HF) patients from three centers treated with a quadripolar CRT system (Abbott) were enrolled. The total of 122 patients were divided into BiV+SyncAV (n = 68) and BiV groups (n = 54) according to whether they underwent CRT with or without SyncAV. Electrocardiographic, echocardiographic, and clinical data were assessed at baseline and during follow-up. Echocardiographic response to CRT was defined as a ≥15% decrease in left ventricular end-systolic volume (LVESV), and clinical response was defined as a NYHA class reduction of ≥1. At the 6-month follow-up, the baseline QRSd and LVESV decreased more significantly in the BiV+SyncAV than in the BiV group (QRSd −36.25 ± 16.33 vs. −22.72 ± 18.75 ms, P < 0.001; LVESV −54.19 ± 38.87 vs. −25.37 ± 36.48 ml, P < 0.001). Compared to the BiV group, more patients in the BiV+SyncAV group were classified as echocardiographic (82.35 vs. 64.81%; P = 0.036) and clinical responders (83.82 vs. 66.67%; P = 0.033). During follow-up, no deaths due to HF deterioration or severe procedure related complications occurred. Conclusion: Compared to BiV pacing, BiV combined with SyncAV leads to a more significant reduction in QRSd and improves LV remodeling and long-term outcomes in HF patients treated with CRT.
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Affiliation(s)
- Zhongkai Wang
- Department of Cardiology, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Pan Li
- Department of Cardiology, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Bili Zhang
- Department of Cardiology, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Jingjuan Huang
- Department of Cardiology, Shanghai Chest hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Shaoping Chen
- Department of Cardiology, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Zhuhong Cai
- Department of Ultrasound, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Yingyi Qin
- Department of Health Statistics, Second Military Medical University, Shanghai, China
| | - Jihai Fan
- Department of Cardiology, 455th Hospital of Nanjing Military Command, Shanghai, China
| | - Wendong Tang
- Department of Cardiology, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Yongwen Qin
- Department of Cardiology, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Ruogu Li
- Department of Cardiology, Shanghai Chest hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Xianxian Zhao
- Department of Cardiology, Changhai Hospital, Second Military Medical University, Shanghai, China
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21
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Waddingham PH, Lambiase P, Muthumala A, Rowland E, Chow AW. Fusion Pacing with Biventricular, Left Ventricular-only and Multipoint Pacing in Cardiac Resynchronisation Therapy: Latest Evidence and Strategies for Use. Arrhythm Electrophysiol Rev 2021; 10:91-100. [PMID: 34401181 PMCID: PMC8335856 DOI: 10.15420/aer.2020.49] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Accepted: 03/15/2021] [Indexed: 12/11/2022] Open
Abstract
Despite advances in the field of cardiac resynchronisation therapy (CRT), response rates and durability of therapy remain relatively static. Optimising device timing intervals may be the most common modifiable factor influencing CRT efficacy after implantation. This review addresses the concept of fusion pacing as a method for improving patient outcomes with CRT. Fusion pacing describes the delivery of CRT pacing with a programming strategy to preserve intrinsic atrioventricular (AV) conduction and ventricular activation via the right bundle branch. Several methods have been assessed to achieve fusion pacing. QRS complex duration (QRSd) shortening with CRT is associated with improved clinical response. Dynamic algorithm-based optimisation targeting narrowest QRSd in patients with intact AV conduction has shown promise in people with heart failure with left bundle branch block. Individualised dynamic programming achieving fusion may achieve the greatest magnitude of electrical synchrony, measured by QRSd narrowing.
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Affiliation(s)
- Peter H Waddingham
- St Bartholomew's Hospital, Barts Health NHS Trust, London, UK.,William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Pier Lambiase
- St Bartholomew's Hospital, Barts Health NHS Trust, London, UK.,UCL Institute of Cardiovascular Science University College London, London, UK
| | - Amal Muthumala
- St Bartholomew's Hospital, Barts Health NHS Trust, London, UK
| | - Edward Rowland
- St Bartholomew's Hospital, Barts Health NHS Trust, London, UK
| | - Anthony Wc Chow
- St Bartholomew's Hospital, Barts Health NHS Trust, London, UK.,William Harvey Research Institute, Queen Mary University of London, London, UK
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22
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Pujol-López M, Tolosana JM, Guasch E, Trucco E, Jiménez-Arjona R, Borràs R, Garre P, San Antonio R, Doltra A, Roca-Luque I, Arbelo E, Alarcón F, Castel MÁ, Sitges M, Varma N, Mont L. Cardiac Resynchronization Therapy Response Is Equalized in Men and Women by Electrical Optimization: PR Matters. JACC Clin Electrophysiol 2021; 7:1400-1409. [PMID: 34217660 DOI: 10.1016/j.jacep.2021.03.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 03/08/2021] [Accepted: 03/28/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVES This study hypothesized that the shorter intrinsic PR interval observed in women allows a greater degree of fusion with intrinsic conduction, achieving a shorter QRS interval duration and, thus, a better response. BACKGROUND Women benefit more from cardiac resynchronization therapy (CRT) than men. However, the reason for this difference remains elusive. METHODS A cohort of 180 patients included in the BEST (Fusion based optimization in resynchronization therapy [ECG Optimization of CRT: Evaluation of Mid-Term Response]; NCT01439529) study were retrospectively analyzed. Patients were initially randomized to either nonoptimized CRT (NON-OPT group; n = 89) or electrocardiographically optimized CRT based on the fusion-optimized intervals (FOI) method (FOI group; n = 91). Echocardiographic response was defined as a >15% decrease in left ventricular end-systolic volume at the 12-month follow-up. RESULTS The basal PR interval was shorter in women as compared to men. In the NON-OPT group, CRT resulted in a shorter paced QRS interval in women than in men (134 ± 21 ms vs. 151 ± 21 ms, respectively; p = 0.003, 95% confidence interval [CI]: -27 to -5.6) and better response in women than in men: 70.4% vs. 46.4%, respectively (odds ratio: 0.37; p = 0.04; 95% CI: 0.14 to 0.97). There were no differences in paced QRS interval duration (126 ± 13 ms vs. 129 ± 17 ms; p = 0.47) or response between women and men in the FOI group (68% vs. 70.5%; odds ratio: 1.12; p = 0.82; 95% CI: 0.41 to 3.07). FOI extended the atrioventricular interval to obtain the best fusion; the atrioventricular intervals tended to require greater extension in men than in women (22 ± 33 ms vs. 8 ± 28 ms, respectively; p = 0.07). CONCLUSIONS Women had a shorter PR interval, which was associated with a shorter QRS interval and better response to CRT. The difference in QRS interval duration and response between men and women did not persist when CRT was optimized using fusion with intrinsic conduction (FOI programming).
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Affiliation(s)
- Margarida Pujol-López
- Institut Clínic Cardiovascular, Hospital Clínic, Universitat de Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Catalonia, Spain
| | - José María Tolosana
- Institut Clínic Cardiovascular, Hospital Clínic, Universitat de Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Catalonia, Spain; Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares, Madrid, Spain
| | - Eduard Guasch
- Institut Clínic Cardiovascular, Hospital Clínic, Universitat de Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Catalonia, Spain; Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares, Madrid, Spain.
| | - Emilce Trucco
- Arrhythmia Section, Cardiology Department, Hospital Universitari Doctor Josep Trueta, Girona, Catalonia, Spain
| | - Rafael Jiménez-Arjona
- Institut Clínic Cardiovascular, Hospital Clínic, Universitat de Barcelona, Catalonia, Spain
| | - Roger Borràs
- Institut Clínic Cardiovascular, Hospital Clínic, Universitat de Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Catalonia, Spain
| | - Paz Garre
- Institut Clínic Cardiovascular, Hospital Clínic, Universitat de Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Catalonia, Spain
| | - Rodolfo San Antonio
- Institut Clínic Cardiovascular, Hospital Clínic, Universitat de Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Catalonia, Spain; Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares, Madrid, Spain
| | - Ada Doltra
- Institut Clínic Cardiovascular, Hospital Clínic, Universitat de Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Catalonia, Spain
| | - Ivo Roca-Luque
- Institut Clínic Cardiovascular, Hospital Clínic, Universitat de Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Catalonia, Spain
| | - Elena Arbelo
- Institut Clínic Cardiovascular, Hospital Clínic, Universitat de Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Catalonia, Spain; Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares, Madrid, Spain
| | - Francisco Alarcón
- Institut Clínic Cardiovascular, Hospital Clínic, Universitat de Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Catalonia, Spain; Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares, Madrid, Spain
| | - María Ángeles Castel
- Institut Clínic Cardiovascular, Hospital Clínic, Universitat de Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Catalonia, Spain; Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares, Madrid, Spain
| | - Marta Sitges
- Institut Clínic Cardiovascular, Hospital Clínic, Universitat de Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Catalonia, Spain; Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares, Madrid, Spain
| | - Niraj Varma
- Cardiac Electrophysiology, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Lluís Mont
- Institut Clínic Cardiovascular, Hospital Clínic, Universitat de Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Catalonia, Spain; Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares, Madrid, Spain.
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23
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Li J, Wang Y, Mai J, Chen S, Liu M, Su C, Chen X, Huang H, Ma Y, Feng C, Jiang J, Liu J, He J, Tang A, Dong Y, Huang X, Chen Y, Wang L. An electrographic AV optimization for the maximum integrative atrioventricular and ventricular resynchronization in CRT. BMC Cardiovasc Disord 2021; 21:288. [PMID: 34112089 PMCID: PMC8193898 DOI: 10.1186/s12872-021-02096-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Accepted: 06/03/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Atrioventricular (AV) delay could affect AV and ventricular synchrony in cardiac resynchronization therapy (CRT). Strategies to optimize AV delay according to optimal AV synchrony (AVopt-AV) or ventricular synchrony (AVopt-V) would potentially be discordant. This study aimed to explore a new AV delay optimization algorithm guided by electrograms to obtain the maximum integrative effects of AV and ventricular resynchronization (opt-AV). METHODS Forty-nine patients with CRT were enrolled. AVopt-AV was measured through the Ritter method. AVopt-V was obtained by yielding the narrowest QRS. The opt-AV was considered to be AVopt-AV or AVopt-V when their difference was < 20 ms, and to be the AV delay with the maximal aortic velocity-time integral between AVopt-AV and AVopt-V when their difference was > 20 ms. RESULTS The results showed that sensing/pacing AVopt-AV (SAVopt-AV/PAVopt-AV) were correlated with atrial activation time (Pend-As/Pend-Ap) (P < 0.05). Sensing/pacing AVopt-V (SAVopt-V/PAVopt-V) was correlated with the intrinsic AV conduction time (As-Vs/Ap-Vs) (P < 0.01). The percentages of patients with more than 20 ms differences between SAVopt-AV/PAVopt-AV and SAVopt-V/PAVopt-V were 62.9% and 57.1%, respectively. Among them, opt-AV was linearly correlated with SAVopt-AV/PAVopt-AV and SAVopt-V/PAVopt-V. The sensing opt-AV (opt-SAV) = 0.1 × SAVopt-AV + 0.4 × SAVopt-V + 70 ms (R2 = 0.665, P < 0.01) and the pacing opt-AV (opt-PAV) = 0.25 × PAVopt-AV + 0.5 × PAVopt-V + 30 ms (R2 = 0.560, P < 0.01). CONCLUSION The SAVopt-AV/PAVopt-AV and SAVopt-V/PAVopt-V were correlated with the atrial activation time and the intrinsic AV conduction interval respectively. Almost half of the patients had a > 20 ms difference between SAVopt-AV/PAVopt-AV and SAVopt-V/PAVopt-V. The opt-AV could be estimated based on electrogram parameters.
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Affiliation(s)
- Jie Li
- Department of Cardiology, The First Affiliated Hospital of Sun Yat-Sen University, No. 58, Zhongshan 2nd Rd, Guangzhou, 510080, Guangdong, People's Republic of China.,Key Laboratory On Assisted Circulation, Ministry of Health, Guangzhou, People's Republic of China
| | - Yuegang Wang
- Department of Cardiology, Nanfang Hospital of Southern Medical University, Guangzhou, People's Republic of China
| | - Jingting Mai
- Department of Cardiology, Sun Yat-Sen Memorial Hospital of Sun Yat-Sen University, No.107, Yanjianxi Rd, Guangzhou, 510080, Guangdong, People's Republic of China
| | - Shilan Chen
- Department of Cardiology, The First Affiliated Hospital of Sun Yat-Sen University, No. 58, Zhongshan 2nd Rd, Guangzhou, 510080, Guangdong, People's Republic of China.,Key Laboratory On Assisted Circulation, Ministry of Health, Guangzhou, People's Republic of China
| | - Menghui Liu
- Department of Cardiology, The First Affiliated Hospital of Sun Yat-Sen University, No. 58, Zhongshan 2nd Rd, Guangzhou, 510080, Guangdong, People's Republic of China.,Key Laboratory On Assisted Circulation, Ministry of Health, Guangzhou, People's Republic of China
| | - Chen Su
- Department of Cardiology, The First Affiliated Hospital of Sun Yat-Sen University, No. 58, Zhongshan 2nd Rd, Guangzhou, 510080, Guangdong, People's Republic of China.,Key Laboratory On Assisted Circulation, Ministry of Health, Guangzhou, People's Republic of China
| | - Xumiao Chen
- Department of Cardiology, The First Affiliated Hospital of Sun Yat-Sen University, No. 58, Zhongshan 2nd Rd, Guangzhou, 510080, Guangdong, People's Republic of China.,Key Laboratory On Assisted Circulation, Ministry of Health, Guangzhou, People's Republic of China
| | - Huiling Huang
- Department of Cardiology, The First Affiliated Hospital of Sun Yat-Sen University, No. 58, Zhongshan 2nd Rd, Guangzhou, 510080, Guangdong, People's Republic of China.,Key Laboratory On Assisted Circulation, Ministry of Health, Guangzhou, People's Republic of China
| | - Yuedong Ma
- Department of Cardiology, The First Affiliated Hospital of Sun Yat-Sen University, No. 58, Zhongshan 2nd Rd, Guangzhou, 510080, Guangdong, People's Republic of China.,Key Laboratory On Assisted Circulation, Ministry of Health, Guangzhou, People's Republic of China
| | - Chong Feng
- Department of Cardiology, The First Affiliated Hospital of Sun Yat-Sen University, No. 58, Zhongshan 2nd Rd, Guangzhou, 510080, Guangdong, People's Republic of China.,Key Laboratory On Assisted Circulation, Ministry of Health, Guangzhou, People's Republic of China
| | - Jingzhou Jiang
- Department of Cardiology, The First Affiliated Hospital of Sun Yat-Sen University, No. 58, Zhongshan 2nd Rd, Guangzhou, 510080, Guangdong, People's Republic of China.,Key Laboratory On Assisted Circulation, Ministry of Health, Guangzhou, People's Republic of China
| | - Jun Liu
- Department of Cardiology, The First Affiliated Hospital of Sun Yat-Sen University, No. 58, Zhongshan 2nd Rd, Guangzhou, 510080, Guangdong, People's Republic of China.,Key Laboratory On Assisted Circulation, Ministry of Health, Guangzhou, People's Republic of China
| | - Jiangui He
- Department of Cardiology, The First Affiliated Hospital of Sun Yat-Sen University, No. 58, Zhongshan 2nd Rd, Guangzhou, 510080, Guangdong, People's Republic of China.,Key Laboratory On Assisted Circulation, Ministry of Health, Guangzhou, People's Republic of China
| | - Anli Tang
- Department of Cardiology, The First Affiliated Hospital of Sun Yat-Sen University, No. 58, Zhongshan 2nd Rd, Guangzhou, 510080, Guangdong, People's Republic of China.,Key Laboratory On Assisted Circulation, Ministry of Health, Guangzhou, People's Republic of China
| | - Yugang Dong
- Department of Cardiology, The First Affiliated Hospital of Sun Yat-Sen University, No. 58, Zhongshan 2nd Rd, Guangzhou, 510080, Guangdong, People's Republic of China.,Key Laboratory On Assisted Circulation, Ministry of Health, Guangzhou, People's Republic of China
| | - Xiaobo Huang
- Department of Cardiology, Nanfang Hospital of Southern Medical University, Guangzhou, People's Republic of China
| | - Yangxin Chen
- Department of Cardiology, Sun Yat-Sen Memorial Hospital of Sun Yat-Sen University, No.107, Yanjianxi Rd, Guangzhou, 510080, Guangdong, People's Republic of China.
| | - Lichun Wang
- Department of Cardiology, The First Affiliated Hospital of Sun Yat-Sen University, No. 58, Zhongshan 2nd Rd, Guangzhou, 510080, Guangdong, People's Republic of China.
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Odland HH, Holm T, Gammelsrud LO, Cornelussen R, Kongsgaard E. Determinants of LV dP/dt max and QRS duration with different fusion strategies in cardiac resynchronisation therapy. Open Heart 2021; 8:e001615. [PMID: 33963078 PMCID: PMC8108692 DOI: 10.1136/openhrt-2021-001615] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 03/13/2021] [Accepted: 04/16/2021] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND We designed this study to assess the acute effects of different fusion strategies and left ventricular (LV) pre-excitation/post-excitation on LV dP/dtmax and QRS duration (QRSd). METHODS We measured LV dP/dtmax and QRSd in 19 patients having cardiac resynchronisation therapy (CRT). Two groups of biventricular pacing were compared: pacing the left ventricle (LV) with FUSION with intrinsic right ventricle (RV) activation (FUSION), and pacing the LV and RV with NO FUSION with intrinsic RV activation. In the NO FUSION group, the RV was paced before the expected QRS onset. A quadripolar LV lead enabled distal, proximal and multipoint pacing (MPP). The LV was stimulated relative in time to either RV pace or QRS-onset in four pre-excitation/post-excitation classes (PCs). We analysed the interactions of two groups (FUSION/NO FUSION) with three different electrode configurations, each paced with four different degrees of LV pre-excitation (PC1-4) in a statistical model. RESULTS LV dP/dtmax was higher with NO FUSION than with FUSION (769±46 mm Hg/s vs 746±46 mm Hg/s, p<0.01), while there was no difference in QRSd (NO FUSION 156±2 ms and FUSION 155±2 ms). LV dP/dtmax and QRSd increased with LV pre-excitation compared with pacing timed to QRS/RV pace-onset regardless of electrode configuration. Overall, pacing LV close to QRS-onset (FUSION) with MPP shortened QRSd the most, while LV dP/dtmax increased the most with LV pre-excitation. CONCLUSION We show how a beneficial change in QRSd dissociates from the haemodynamic change in LV dP/dtmax with different biventricular pacing strategies. In this study, LV pre-excitation was the main determinant of LV dP/dtmax, while QRSd shortens with optimal resynchronisation.
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Affiliation(s)
- Hans Henrik Odland
- Department of Cardiology and Pediatric Cardiology, Oslo University Hospital, Oslo, Norway
| | - Torbjørn Holm
- Department of Cardiology, Oslo University Hospital, Oslo, Norway
| | | | | | - Erik Kongsgaard
- Department of Cardiology, Oslo University Hospital, Oslo, Norway
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25
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Abstract
Cardiac resynchronization therapy (CRT) is an established treatment of patients with medically refractory, mild-to-severe systolic heart failure (HF), impaired left ventricular function, and wide QRS complex. The pathologic activation sequence observed in patients with abnormal QRS duration and morphology results in a dyssynchronous ventricular activation and contraction leading to cardiac remodeling, worsening systolic and diastolic function, and progressive HF. In this article, the authors aim to explore the current CRT literature, focusing their attentions on the promising innovation in this field.
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26
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San Antonio R, Guasch E, González-Ascaso A, Jiménez-Arjona R, Climent AM, Pujol-López M, Doltra A, Alarcón F, Garre P, Liberos A, Trotta O, Quinto L, Borràs R, Arbelo E, Roca-Luque I, Atienza F, Brugada J, Fernández-Avilés F, Guillem MS, Sitges M, Tolosana JM, Mont L. Optimized single-point left ventricular pacing leads to improved resynchronization compared with multipoint pacing. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2021; 44:519-527. [PMID: 33538337 DOI: 10.1111/pace.14185] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Revised: 01/15/2021] [Accepted: 01/24/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Multipoint pacing (MPP) in cardiac resynchronization therapy (CRT) activates the left ventricle from two locations, thereby shortening the QRS duration and enabling better resynchronization; however, compared with conventional CRT, MPP reduces battery longevity. On the other hand, electrocardiogram-based optimization using the fusion-optimized intervals (FOI) method achieves more significant reverse remodeling than nominal CRT programming. Our study aimed to determine whether MPP could attain better resynchronization than single-point pacing (SPP) optimized by FOI. METHODS This prospective study included 32 consecutive patients who successfully received CRT devices with MPP capabilities. After implantation, the QRS duration was measured during intrinsic rhythm and with three pacing configurations: MPP, SPP-FOI, and MPP-FOI. In 14 patients, biventricular activation times (by electrocardiographic imaging, ECGI) were obtained during intrinsic rhythm and for each pacing configuration to validate the findings. Device battery longevity was estimated at the 45-day follow-up. RESULTS The SPP-FOI method achieved greater QRS shortening than MPP (-56 ± 16 vs. -42 ± 17 ms, p < .001). Adding MPP to the best FOI programming did not result in further shortening (MPP-FOI: -58 ± 14 ms, p = .69). Although biventricular activation times did not differ significantly among the three pacing configurations, only the two FOI configurations achieved significant shortening compared with intrinsic rhythm. The estimated battery longevity was longer with SPP than with MPP (8.1 ± 2.3 vs. 6.3 ± 2.0 years, p = .03). CONCLUSIONS SPP optimized by FOI resulted in better resynchronization and longer battery duration than MPP.
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Affiliation(s)
- Rodolfo San Antonio
- Institut Clínic Cardio-Vascular, Hospital Clínic, University of Barcelona, Barcelona, Catalonia, Spain.,Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain.,Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Catalonia, Spain
| | - Eduard Guasch
- Institut Clínic Cardio-Vascular, Hospital Clínic, University of Barcelona, Barcelona, Catalonia, Spain.,Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain.,Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Catalonia, Spain
| | - Ana González-Ascaso
- ITACA Institute, Universitat Politècnica de València, Camino de Vera s/n, Valencia, Spain
| | - Rafael Jiménez-Arjona
- Institut Clínic Cardio-Vascular, Hospital Clínic, University of Barcelona, Barcelona, Catalonia, Spain
| | - Andreu M Climent
- ITACA Institute, Universitat Politècnica de València, Camino de Vera s/n, Valencia, Spain
| | - Margarida Pujol-López
- Institut Clínic Cardio-Vascular, Hospital Clínic, University of Barcelona, Barcelona, Catalonia, Spain
| | - Adelina Doltra
- Institut Clínic Cardio-Vascular, Hospital Clínic, University of Barcelona, Barcelona, Catalonia, Spain
| | - Francisco Alarcón
- Institut Clínic Cardio-Vascular, Hospital Clínic, University of Barcelona, Barcelona, Catalonia, Spain
| | - Paz Garre
- Institut Clínic Cardio-Vascular, Hospital Clínic, University of Barcelona, Barcelona, Catalonia, Spain
| | - Alejandro Liberos
- ITACA Institute, Universitat Politècnica de València, Camino de Vera s/n, Valencia, Spain
| | - Omar Trotta
- Institut Clínic Cardio-Vascular, Hospital Clínic, University of Barcelona, Barcelona, Catalonia, Spain
| | - Levio Quinto
- Institut Clínic Cardio-Vascular, Hospital Clínic, University of Barcelona, Barcelona, Catalonia, Spain
| | - Roger Borràs
- Institut Clínic Cardio-Vascular, Hospital Clínic, University of Barcelona, Barcelona, Catalonia, Spain
| | - Elena Arbelo
- Institut Clínic Cardio-Vascular, Hospital Clínic, University of Barcelona, Barcelona, Catalonia, Spain.,Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Catalonia, Spain
| | - Ivo Roca-Luque
- Institut Clínic Cardio-Vascular, Hospital Clínic, University of Barcelona, Barcelona, Catalonia, Spain
| | - Felipe Atienza
- Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain.,Cardiology Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain, Instituto de Investigación Sanitaria Gregorio Marañon (IISGM), Madrid, Spain
| | - Josep Brugada
- Institut Clínic Cardio-Vascular, Hospital Clínic, University of Barcelona, Barcelona, Catalonia, Spain.,Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain.,Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Catalonia, Spain
| | - Francisco Fernández-Avilés
- Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain.,Cardiology Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain, Instituto de Investigación Sanitaria Gregorio Marañon (IISGM), Madrid, Spain
| | - María S Guillem
- ITACA Institute, Universitat Politècnica de València, Camino de Vera s/n, Valencia, Spain
| | - Marta Sitges
- Institut Clínic Cardio-Vascular, Hospital Clínic, University of Barcelona, Barcelona, Catalonia, Spain.,Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain.,Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Catalonia, Spain
| | - Jose María Tolosana
- Institut Clínic Cardio-Vascular, Hospital Clínic, University of Barcelona, Barcelona, Catalonia, Spain.,Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain.,Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Catalonia, Spain
| | - Lluís Mont
- Institut Clínic Cardio-Vascular, Hospital Clínic, University of Barcelona, Barcelona, Catalonia, Spain.,Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain.,Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Catalonia, Spain
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27
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Bianchi V, Martiniello AR, Mangual J, Tavoletta V, Pedrizzetti G, Tonti G, Caso VM, Caso P, D'Onofrio A. Impact of synchronous atrioventricular delay optimization on left ventricle flow force angle evaluated by echocardiographic particle image velocimetry. J Interv Card Electrophysiol 2021; 63:1-8. [PMID: 33474704 DOI: 10.1007/s10840-020-00923-7] [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: 10/20/2020] [Accepted: 12/27/2020] [Indexed: 11/25/2022]
Abstract
PURPOSE To evaluate the improvement in electrical synchrony and left ventricle (LV) hemodynamics provided by combining the dynamic atrioventricular delay (AVD) of SyncAVTM CRT and the multiple LV pacing sites of MultiPoint pacing (MPP). METHODS Patients with LBBB and QRS duration (QRSd) > 140 ms implanted with a CRT-D or CRT-P device and quadripolar LV lead were enrolled in this prospective study. During a post-implant follow-up visit, QRSd was measured from 12-lead surface electrograms by experts blinded to pacing configurations. QRSd reduction relative to intrinsic rhythm was evaluated during biventricular pacing (BiV) and MPP for two AVDs: nominal (140/110 ms paced/sensed) and SyncAV (patient-optimized SyncAV offset [10-60 ms] minimizing QRSd). Echocardiography particle imaging velocimetry (Echo-PIV) analysis was performed for each configuration. The resulting hemodynamic force LV flow angle (φ) was analyzed, which ranges from 0o (predominantly base-apex forces) to 90o (predominantly transverse forces). Higher angles indicate more energy dissipation at lateral walls due to transverse flow; lower angles indicate healthier flow aligned with the longitudinal base-apex path of the pressure gradient. RESULTS Twelve patients (58% male, 17% ischemic, 32±7% ejection fraction, 165 ± 18 ms intrinsic QRSd) completed QRSd and Echo-PIV assessment. Relative to intrinsic rhythm, BiV and MPP with nominal AVD reduced QRSd by 10 ± 9% and 12 ± 9%, respectively. BiV+SyncAV and MPP+SyncAV further reduced QRSd by 19 ± 8%, (p < 0.05 vs. BiV with nominal AVD) and 23 ± 9% (p < 0.05 vs BiV+SyncAV), respectively. Echo-PIV showed similar sequential hemodynamic improvements. LV flow angular orientation during intrinsic activation (46 ± 3o) reduced with BiV+SyncAV (37 ± 4o, p < 0.05 vs intrinsic) and further with MPP+SyncAV (34 ± 4o, p < 0.05 vs BiV+SyncAV). CONCLUSION These results suggest that SyncAV may improve electrical synchrony and influence LV flow patterns in patients suffering from heart failure compared to conventional CRT with a fixed AVD, with further improvement observed by combining with MPP.
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Affiliation(s)
- Valter Bianchi
- Department of Cardiology, Monaldi Hospital, AORN Ospedali dei Colli, Napoli, Italy.
| | | | | | - Vincenzo Tavoletta
- Department of Cardiology, Monaldi Hospital, AORN Ospedali dei Colli, Napoli, Italy
| | - Gianni Pedrizzetti
- Department of Engineering and Architecture, University of Trieste, Trieste, Italy
| | - Giovanni Tonti
- Cardiology Division, "G. D'Annunzio" University, Chieti, Italy
| | - Valentina Maria Caso
- Department of Cardiology, Monaldi Hospital, AORN Ospedali dei Colli, Napoli, Italy
| | - Pio Caso
- Department of Cardiology, Monaldi Hospital, AORN Ospedali dei Colli, Napoli, Italy
| | - Antonio D'Onofrio
- Department of Cardiology, Monaldi Hospital, AORN Ospedali dei Colli, Napoli, Italy
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Wu S, Cai M, Zheng R, Wang S, Jiang L, Xu L, Shi R, Xiao F, Ellenbogen KA, Cha Y, Su L, Huang W. Impact of QRS morphology on response to conduction system pacing after atrioventricular junction ablation. ESC Heart Fail 2021; 8:1195-1203. [PMID: 33395736 PMCID: PMC8006676 DOI: 10.1002/ehf2.13181] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Revised: 11/16/2020] [Accepted: 12/08/2020] [Indexed: 01/03/2023] Open
Abstract
Aims His–Purkinje conduction system pacing (HPCSP) utilizing His (HBP) or left bundle branch pacing (LBBP) in patients with atrial fibrillation (AF) and wide QRS duration has not been well studied. We assessed the benefit of left bundle branch block (LBBB) correction during HPCSP in AF patients undergoing atrioventricular junction (AVJ) ablation with LBBB, compared with those with narrow QRS duration. Methods and results This is an observational study in consecutive patients with typical LBBB or narrow QRS duration in whom we attempted HPCSP after AVJ ablation for refractory AF with a left ventricular ejection fraction (LVEF) ≤ 50%. Echocardiographic responses and clinical outcomes were assessed at baseline and during 1 year of follow‐up. A total of 178 patients were enrolled, of which 170 achieved AVJ ablation + permanent HPCSP (age 69.3 ± 10.1 years; LVEF 34.3 ± 7.7%), 133 (78.2%) patients had a narrow QRS duration, and 37 (21.2%) had an LBBB. The QRS duration changed from a baseline of 159.7 ± 16.6 ms to a paced QRS duration of 110.4 ± 12.7 ms in the LBBB cohort and from 95.6 ± 10.4 to 100.8 ± 14.5 ms (both P < 0.001) in the narrow QRS cohort after AVJ ablation and pacing. Compared with the narrow QRS cohort, the LBBB cohort showed a greater absolute increase in LVEF (+22.3% vs. +14.2%, P < 0.001), higher super responder rate (71.4% vs. 49.2%, P = 0.011), and greater New York Heart Association (NYHA) class improvement (−1.9 vs. −1.4, P < 0.001) at 1 year. Conclusion Patients with LBBB have greater improvement in LVEF and NYHA class function than patients with narrow QRS from HPCSP after AVJ ablation.
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Affiliation(s)
- Shengjie Wu
- Department of Cardiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, China.,The Key Lab of Cardiovascular Disease of Wenzhou, Wenzhou, 325000, China
| | - Mengxing Cai
- Department of Cardiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, China.,The Key Lab of Cardiovascular Disease of Wenzhou, Wenzhou, 325000, China
| | - Rujie Zheng
- Department of Cardiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, China.,The Key Lab of Cardiovascular Disease of Wenzhou, Wenzhou, 325000, China
| | - Songjie Wang
- Department of Cardiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, China.,The Key Lab of Cardiovascular Disease of Wenzhou, Wenzhou, 325000, China
| | - Limeng Jiang
- Department of Cardiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, China.,The Key Lab of Cardiovascular Disease of Wenzhou, Wenzhou, 325000, China
| | - Lei Xu
- Department of Cardiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, China.,The Key Lab of Cardiovascular Disease of Wenzhou, Wenzhou, 325000, China
| | - Ruiyu Shi
- Department of Cardiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, China.,The Key Lab of Cardiovascular Disease of Wenzhou, Wenzhou, 325000, China
| | - Fangyi Xiao
- Department of Cardiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, China.,The Key Lab of Cardiovascular Disease of Wenzhou, Wenzhou, 325000, China
| | - Kenneth A Ellenbogen
- Department of Cardiology, Virginia Commonwealth University Health System, Richmond, VA, USA
| | - Yongmei Cha
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Lan Su
- Department of Cardiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, China.,The Key Lab of Cardiovascular Disease of Wenzhou, Wenzhou, 325000, China
| | - Weijian Huang
- Department of Cardiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, China.,The Key Lab of Cardiovascular Disease of Wenzhou, Wenzhou, 325000, China
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29
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Pujol-López M, Guasch E, Jiménez-Arjona R, San Antonio R, Mont L, Tolosana JM. Left Bundle Branch Pacing: A New Alternative to Resynchronization Therapy in the 2020 Pacing Armamentarium. JACC Case Rep 2020; 2:2225-2229. [PMID: 34317145 PMCID: PMC8299856 DOI: 10.1016/j.jaccas.2020.07.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 06/01/2020] [Accepted: 07/01/2020] [Indexed: 11/19/2022]
Abstract
His bundle pacing was developed while seeking a physiological alternative to biventricular cardiac resynchronization therapy. However, His bundle pacing may not be adequate in all patients. In this scenario, left bundle branch pacing has arisen as a new cardiac resynchronization therapy modality to correct left bundle branch block and restore ventricular synchrony. (Level of Difficulty: Intermediate.).
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Affiliation(s)
- Margarida Pujol-López
- Arrhythmia Section, Institut Clínic Cardiovascular, Hospital Clínic, Universitat de Barcelona, Catalonia, Spain
| | - Eduard Guasch
- Arrhythmia Section, Institut Clínic Cardiovascular, Hospital Clínic, Universitat de Barcelona, Catalonia, Spain
- Institut d’Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Catalonia, Spain
- Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares, Madrid, Spain
| | - Rafael Jiménez-Arjona
- Cardiovascular Imaging Department, Institut Clínic Cardiovascular, Hospital Clínic, Universitat de Barcelona, Catalonia, Spain
| | - Rodolfo San Antonio
- Arrhythmia Section, Institut Clínic Cardiovascular, Hospital Clínic, Universitat de Barcelona, Catalonia, Spain
- Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares, Madrid, Spain
| | - Lluís Mont
- Arrhythmia Section, Institut Clínic Cardiovascular, Hospital Clínic, Universitat de Barcelona, Catalonia, Spain
- Institut d’Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Catalonia, Spain
- Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares, Madrid, Spain
| | - José M. Tolosana
- Arrhythmia Section, Institut Clínic Cardiovascular, Hospital Clínic, Universitat de Barcelona, Catalonia, Spain
- Institut d’Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Catalonia, Spain
- Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares, Madrid, Spain
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Electrical synchronization achieved by multipoint pacing combined with dynamic atrioventricular delay. J Interv Card Electrophysiol 2020; 61:453-460. [DOI: 10.1007/s10840-020-00842-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 07/27/2020] [Indexed: 10/23/2022]
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Blanchette M. Cardiac resynchronization therapy setting personalization utilizing noninvasive hemodynamics. Heart Lung 2020; 50:165-167. [PMID: 32711894 DOI: 10.1016/j.hrtlng.2020.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 07/01/2020] [Accepted: 07/06/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Cardiac resynchronization therapy (CRT) has been an important adjunct to goal directed medical therapy in heart failure patients who qualify for this device. Too often, when heart failure patients complain about severe fatigue, beta-blockers are immediately reduced. Personalization of settings, verified by noninvasive hemodynamics, can allow for maximizing medical therapy. CASE A newly diagnosed 40 year-old male presented to the heart failure clinic post hospital discharge with a severely dilated, non-ischemic cardiomyopathy. Even with an ejection fraction (EF) of 15-20%, he reports "feeling great". Increasing medications resulted in excessive fatigue. Non-invasive studies showed an average cardiac index (CI) of 1.5l/min/m2. It was decided to personalize his settings. Changes made increased his CI to 3.9l/min/m2. CONCLUSION Combining current available technology with noninvasive studies significantly improved his CI and no reduction in beta-blocker therapy was necessary. CRT personalization can be of significant value for the heart failure patient.
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Affiliation(s)
- Michael Blanchette
- Sarasota Memorial Health Care System, Heart Failure Center, 1700 South Tamiami Trail, Sarasota, FL 34239, United States.
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Solimene F, Nigro G, Canciello M, Tavoletta V, Shopova G, Calvanese R, Rago A, La Rosa C, Nappi F, Viscusi M, Urraro F, Manzo G, Gallo P, Andriani A, Rovaris G, Palmisano P, Innocenti S, D'Onofrio A. Design and rationale of the Impact of MultiPoint pacing in CRT patients with reduced RV-to-LV delay (IMAGE-CRT) study. J Cardiovasc Med (Hagerstown) 2020; 21:250-258. [PMID: 32004245 DOI: 10.2459/jcm.0000000000000928] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Cardiac resynchronization therapy (CRT) is an established treatment in patients with heart failure and prolonged QRS duration. A biventricular device is implanted to achieve faster activation and more synchronous contraction of the ventricles. Despite the convincing effect of CRT, 30-40% of patients do not respond. We decided to investigate the role of multipoint pacing (MPP) in a selected group of patients with right ventricle (RV)-to-left ventricle (LV) intervals less than 80 ms that do not respond to traditional CRT. METHODS We will enrol 248 patients in this patient-blinded, observational, clinical study aiming to investigate if MPP could decrease LV end-systolic volume (ESV) in patients with RV-to-LV interval less than 80 ms. MPP will be activated ON at implant in patients with RV-to-LV delay less than 80 ms and OFF in RV-to-LV at least 80 ms. At follow-up the activation of MPP will be related to CRT response. The primary study endpoint will be the responder rate at 6 months, defined as a decrease in LV ejection fraction, LV end-diastolic volume, LV end-systolic volume (LVESV) at least 15% from baseline. Secondary outcomes include 12 months relative percentage reduction in LVESV and a combined clinical outcome measure of response to CRT defined as the patient being alive, no hospitalization due to heart failure, and experiencing an improvement in New York Heart Association functional class (Composite-Score). CONCLUSION Reducing the nonresponder rate continues to be an important goal for CRT.If an increase in reverse remodelling can be achieved by MPP, this study supports the conduct of larger trials investigating the role of MPP on clinical outcomes in selected patients treated, right now, only with traditional CRT. TRIAL REGISTRATION ClinicalTrials.gov, NCT02713308. Registered on 18 March 2016.
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Affiliation(s)
| | - Gerardo Nigro
- University of Campania 'Luigi Vanvitelli', Monaldi Hospital
| | | | | | | | | | - Anna Rago
- University of Campania 'Luigi Vanvitelli', Monaldi Hospital
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AlTurki A, Lima PY, Bernier ML, Garcia D, Vidal A, Toscani B, Diaz S, Montemezzo M, Al-Dossari A, Hadjis T, Joza J, Essebag V. Optimization of Chronic Cardiac Resynchronization Therapy Using Fusion Pacing Algorithm Improves Echocardiographic Response. CJC Open 2020; 2:62-70. [PMID: 32190827 PMCID: PMC7067690 DOI: 10.1016/j.cjco.2019.12.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Accepted: 12/22/2019] [Indexed: 11/15/2022] Open
Abstract
Background Whether reprogramming of cardiac resynchronization therapy (CRT) to increase electrical synchrony translates into echocardiographic improvement remains unclear. SyncAV is an algorithm that allows fusion of intrinsic conduction with biventricular pacing. We aimed to assess whether reprogramming chronically implanted CRT devices with SyncAV is associated with improved echocardiographic parameters. Methods Patients at a quaternary center with previously implanted CRT devices with a programmable SyncAV algorithm underwent routine electrocardiography-based SyncAV optimization during regular device clinic visits. This analysis included only patients who could be programmed to the SyncAV algorithm (i.e., in sinus rhythm with intrinsic atrioventricular conduction). Echocardiography was performed before and 6 months after CRT optimization. Results Of 64 consecutive, potentially eligible patients who underwent assessment, 34 who were able to undergo SyncAV programming were included. Their mean age was 74 ± 9 years, 41% were female, and 59% had ischemic cardiomyopathy. The mean time from CRT implant to SyncAV optimization was 17.8 ± 8.5 months. At 6-month follow-up, SyncAV optimization was associated with a significant increase in left ventricular ejection fraction (LVEF) (mean LVEF 36.5% ± 13.3% vs 30.9% ± 13.3%; P < 0.001) and a reduction in left ventricular end-systolic volume (LVESV) (mean LVESV 110.5 ± 57.5 mL vs 89.6 ± 52.4 mL; P < 0.001) compared with baseline existing CRT programming. Conclusion CRT reprogramming to maximize biventricular fusion pacing significantly increased LVEF and reduced LVESV in patients with chronic CRT devices. Further studies are needed to assess if a continuous fusion pacing algorithm improves long-term clinical outcomes and to identify which patients are most likely to derive benefit.
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Affiliation(s)
- Ahmed AlTurki
- Division of Cardiology, McGill University Health Center, Montreal, Quebec, Canada
| | - Pedro Y Lima
- Division of Cardiology, McGill University Health Center, Montreal, Quebec, Canada
| | - Martin L Bernier
- Division of Cardiology, McGill University Health Center, Montreal, Quebec, Canada
| | - Daniel Garcia
- Division of Cardiology, McGill University Health Center, Montreal, Quebec, Canada
| | - Alejandro Vidal
- Division of Cardiology, McGill University Health Center, Montreal, Quebec, Canada
| | - Bruno Toscani
- Division of Cardiology, McGill University Health Center, Montreal, Quebec, Canada
| | - Sergio Diaz
- Division of Cardiology, McGill University Health Center, Montreal, Quebec, Canada
| | - Mauricio Montemezzo
- Division of Cardiology, McGill University Health Center, Montreal, Quebec, Canada
| | - Alaa Al-Dossari
- Division of Cardiology, McGill University Health Center, Montreal, Quebec, Canada
| | - Tomy Hadjis
- Division of Cardiology, McGill University Health Center, Montreal, Quebec, Canada
| | - Jacqueline Joza
- Division of Cardiology, McGill University Health Center, Montreal, Quebec, Canada
| | - Vidal Essebag
- Division of Cardiology, McGill University Health Center, Montreal, Quebec, Canada
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Noheria A, Sodhi S, Orme GJ. The Evolving Role of Electrocardiography in Cardiac Resynchronization Therapy. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2019; 21:91. [DOI: 10.1007/s11936-019-0784-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Pujol-López M, San Antonio R, Mont L, Trucco E, Tolosana JM, Arbelo E, Guasch E, Heist EK, Singh JP. Electrocardiographic optimization techniques in resynchronization therapy. Europace 2019; 21:1286-1296. [DOI: 10.1093/europace/euz126] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Accepted: 04/05/2019] [Indexed: 12/22/2022] Open
Abstract
Abstract
Cardiac resynchronization therapy (CRT) is a cornerstone of therapy for patients with heart failure, reduced left ventricular (LV) ejection fraction, and a wide QRS complex. However, not all patients respond to CRT: 30% of CRT implanted patients are currently considered clinical non-responders and up to 40% do not achieve LV reverse remodelling. In order to achieve the best CRT response, appropriate patient selection, device implantation, and programming are important factors. Optimization of CRT pacing intervals may improve results, increasing the number of responders, and the magnitude of the response. Echocardiography is considered the reference method for atrioventricular and interventricular (VV) intervals optimization but it is time-consuming, complex and it has a large interobserver and intraobserver variability. Previous studies have linked QRS shortening to clinical response, echocardiographic improvement and favourable prognosis. In this review, we describe the electrocardiographic optimization methods available: 12-lead electrocardiogram; fusion-optimized intervals (FOI); intracardiac electrogram-based algorithms; and electrocardiographic imaging. Fusion-optimized intervals is an electrocardiographic method of optimizing CRT based on QRS duration that combines fusion with intrinsic conduction. The FOI method is feasible and fast, further reduces QRS duration, can be performed during implant, improves acute haemodynamic response, and achieves greater LV remodelling compared with nominal programming of CRT.
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Affiliation(s)
- Margarida Pujol-López
- Cardiology Department, Institut Clínic Cardiovascular (ICCV), Hospital Clínic, Universitat de Barcelona, Barcelona, Catalonia, Spain
| | - Rodolfo San Antonio
- Cardiology Department, Institut Clínic Cardiovascular (ICCV), Hospital Clínic, Universitat de Barcelona, Barcelona, Catalonia, Spain
- Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - Lluís Mont
- Cardiology Department, Institut Clínic Cardiovascular (ICCV), Hospital Clínic, Universitat de Barcelona, Barcelona, Catalonia, Spain
- Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
- Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia, Spain
| | - Emilce Trucco
- Department of Cardiology, Hospital Universitari Doctor Josep Trueta, Girona, Catalonia, Spain
| | - José María Tolosana
- Cardiology Department, Institut Clínic Cardiovascular (ICCV), Hospital Clínic, Universitat de Barcelona, Barcelona, Catalonia, Spain
- Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
- Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia, Spain
| | - Elena Arbelo
- Cardiology Department, Institut Clínic Cardiovascular (ICCV), Hospital Clínic, Universitat de Barcelona, Barcelona, Catalonia, Spain
- Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
- Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia, Spain
| | - Eduard Guasch
- Cardiology Department, Institut Clínic Cardiovascular (ICCV), Hospital Clínic, Universitat de Barcelona, Barcelona, Catalonia, Spain
- Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
- Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia, Spain
| | - Edwin Kevin Heist
- Cardiology Division, Cardiac Arrhythmia Service, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Jagmeet P Singh
- Cardiology Division, Cardiac Arrhythmia Service, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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Carpio EF, Gomez JF, Sebastian R, Lopez-Perez A, Castellanos E, Almendral J, Ferrero JM, Trenor B. Optimization of Lead Placement in the Right Ventricle During Cardiac Resynchronization Therapy. A Simulation Study. Front Physiol 2019; 10:74. [PMID: 30804805 PMCID: PMC6378298 DOI: 10.3389/fphys.2019.00074] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Accepted: 01/22/2019] [Indexed: 12/18/2022] Open
Abstract
Patients suffering from heart failure and left bundle branch block show electrical ventricular dyssynchrony causing an abnormal blood pumping. Cardiac resynchronization therapy (CRT) is recommended for these patients. Patients with positive therapy response normally present QRS shortening and an increased left ventricle (LV) ejection fraction. However, around one third do not respond favorably. Therefore, optimal location of pacing leads, timing delays between leads and/or choosing related biomarkers is crucial to achieve the best possible degree of ventricular synchrony during CRT application. In this study, computational modeling is used to predict the optimal location and delay of pacing leads to improve CRT response. We use a 3D electrophysiological computational model of the heart and torso to get insight into the changes in the activation patterns obtained when the heart is paced from different regions and for different atrioventricular and interventricular delays. The model represents a heart with left bundle branch block and heart failure, and allows a detailed and accurate analysis of the electrical changes observed simultaneously in the myocardium and in the QRS complex computed in the precordial leads. Computational simulations were performed using a modified version of the O'Hara et al. action potential model, the most recent mathematical model developed for human ventricular electrophysiology. The optimal location for the pacing leads was determined by QRS maximal reduction. Additionally, the influence of Purkinje system on CRT response was assessed and correlation analysis between several parameters of the QRS was made. Simulation results showed that the right ventricle (RV) upper septum near the outflow tract is an alternative location to the RV apical lead. Furthermore, LV endocardial pacing provided better results as compared to epicardial stimulation. Finally, the time to reach the 90% of the QRS area was a good predictor of the instant at which 90% of the ventricular tissue was activated. Thus, the time to reach the 90% of the QRS area is suggested as an additional index to assess CRT effectiveness to improve biventricular synchrony.
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Affiliation(s)
- Edison F Carpio
- Centre for Research and Innovation in Bioengineering (Ci2B), Universitat Politècnica de València, Valencia, Spain
| | - Juan F Gomez
- Centre for Research and Innovation in Bioengineering (Ci2B), Universitat Politècnica de València, Valencia, Spain
| | - Rafael Sebastian
- Computational Multiscale Simulation Lab (CoMMLab), Department of Computer Science, Universitat de València, Valencia, Spain
| | - Alejandro Lopez-Perez
- Centre for Research and Innovation in Bioengineering (Ci2B), Universitat Politècnica de València, Valencia, Spain
| | - Eduardo Castellanos
- Electrophysiology Laboratory and Arrhythmia Unit, Grupo HM Hospitales, Hospital Monteprincipe, University CEU-San Pablo, Madrid, Spain
| | - Jesus Almendral
- Electrophysiology Laboratory and Arrhythmia Unit, Grupo HM Hospitales, Hospital Monteprincipe, University CEU-San Pablo, Madrid, Spain
| | - Jose M Ferrero
- Centre for Research and Innovation in Bioengineering (Ci2B), Universitat Politècnica de València, Valencia, Spain
| | - Beatriz Trenor
- Centre for Research and Innovation in Bioengineering (Ci2B), Universitat Politècnica de València, Valencia, Spain
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Tolosana JM, Brugada J. Optimizing Cardiac Resynchronization Therapy Devices in Follow-up to Improve Response Rates and Outcomes. Card Electrophysiol Clin 2019; 11:89-98. [PMID: 30717856 DOI: 10.1016/j.ccep.2018.11.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Although cardiac resynchronization therapy (CRT) will improve symptoms and survival in selected heart failure patients, there still remains a high percentage of CRT recipients who do not obtain benefit from the therapy. During CRT follow-up, an effort should be made to identify and to treat reversible causes of nonresponse to CRT. This effort includes optimization of medical therapy, checking for appropriate and effective biventricular pacing, and treatment of arrhythmias and other reversible causes of CRT malfunction.
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Affiliation(s)
- Jose María Tolosana
- Cardiovascular Institute, Hospital Clínic, Arrhythmia Unit Hospital Clinic, University of Barcelona, Villarroel 170, Barcelona 08036, Spain
| | - Josep Brugada
- Pediatric Arrhythmia Unit, Cardiovascular Institute, Hospital Clínic, Hospital Sant Joan de Déu, University of Barcelona, Barcelona, Spain.
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Jones S, Lumens J, Sohaib SMA, Finegold JA, Kanagaratnam P, Tanner M, Duncan E, Moore P, Leyva F, Frenneaux M, Mason M, Hughes AD, Francis DP, Whinnett ZI. Cardiac resynchronization therapy: mechanisms of action and scope for further improvement in cardiac function. Europace 2018; 19:1178-1186. [PMID: 27411361 PMCID: PMC5834145 DOI: 10.1093/europace/euw136] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Accepted: 04/20/2016] [Indexed: 01/08/2023] Open
Abstract
Aims Cardiac resynchronization therapy (CRT) may exert its beneficial haemodynamic effect by improving ventricular synchrony and improving atrioventricular (AV) timing. The aim of this study was to establish the relative importance of the mechanisms through which CRT improves cardiac function and explore the potential for additional improvements with improved ventricular resynchronization. Methods and Results We performed simulations using the CircAdapt haemodynamic model and performed haemodynamic measurements while adjusting AV delay, at low and high heart rates, in 87 patients with CRT devices. We assessed QRS duration, presence of fusion, and haemodynamic response. The simulations suggest that intrinsic PR interval and the magnitude of reduction in ventricular activation determine the relative importance of the mechanisms of benefit. For example, if PR interval is 201 ms and LV activation time is reduced by 25 ms (typical for current CRT methods), then AV delay optimization is responsible for 69% of overall improvement. Reducing LV activation time by an additional 25 ms produced an additional 2.6 mmHg increase in blood pressure (30% of effect size observed with current CRT). In the clinical population, ventricular fusion significantly shortened QRS duration (Δ-27 ± 23 ms, P < 0.001) and improved systolic blood pressure (mean 2.5 mmHg increase). Ventricular fusion was present in 69% of patients, yet in 40% of patients with fusion, shortening AV delay (to a delay where fusion was not present) produced the optimal haemodynamic response. Conclusions Improving LV preloading by shortening AV delay is an important mechanism through which cardiac function is improved with CRT. There is substantial scope for further improvement if methods for delivering more efficient ventricular resynchronization can be developed. Clinical Trial Registration Our clinical data were obtained from a subpopulation of the British Randomised Controlled Trial of AV and VV Optimisation (BRAVO), which is a registered clinical trial with unique identifier: NCT01258829, https://clinicaltrials.gov
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Affiliation(s)
- Siana Jones
- Institute of Cardiovascular Science, University College London, London WC1E 6BT, UK
| | - Joost Lumens
- CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht 6229 ER, The Netherlands
| | - S M Afzal Sohaib
- NHLI-Cardiovascular Science, Imperial College London, National Heart and Lung Institute, The Hammersmith Hospital, B Block South, 2nd Floor, Du Cane Road, London W12 ONN, UK
| | - Judith A Finegold
- NHLI-Cardiovascular Science, Imperial College London, National Heart and Lung Institute, The Hammersmith Hospital, B Block South, 2nd Floor, Du Cane Road, London W12 ONN, UK
| | - Prapa Kanagaratnam
- NHLI-Cardiovascular Science, Imperial College London, National Heart and Lung Institute, The Hammersmith Hospital, B Block South, 2nd Floor, Du Cane Road, London W12 ONN, UK
| | - Mark Tanner
- St Richards Hospital, Western Sussex Hospitals Foundation Trust, Chichester PO19 6SE, UK
| | - Edward Duncan
- Bristol Royal Infirmary, Marlborough Street, Bristol BS2 8HW, UK
| | - Philip Moore
- Watford General Hospital, Vicarage Road, Watford WD18 0HB, UK
| | - Francisco Leyva
- Queen Elizabeth Hospital, Mindelsohn Way, Edgbaston, Birmingham B15 2WB, UK
| | - Mike Frenneaux
- School of Medicine and Dentistry, University of Aberdeen, Aberdeen, UK
| | - Mark Mason
- Harefield Hospital, Hill End Road, Harefield, Middlesex UB9 6JH, UK
| | - Alun D Hughes
- Institute of Cardiovascular Science, University College London, London WC1E 6BT, UK
| | - Darrel P Francis
- NHLI-Cardiovascular Science, Imperial College London, National Heart and Lung Institute, The Hammersmith Hospital, B Block South, 2nd Floor, Du Cane Road, London W12 ONN, UK
| | - Zachary I Whinnett
- NHLI-Cardiovascular Science, Imperial College London, National Heart and Lung Institute, The Hammersmith Hospital, B Block South, 2nd Floor, Du Cane Road, London W12 ONN, UK
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Varma N, O'Donnell D, Bassiouny M, Ritter P, Pappone C, Mangual J, Cantillon D, Badie N, Thibault B, Wisnoskey B. Programming Cardiac Resynchronization Therapy for Electrical Synchrony: Reaching Beyond Left Bundle Branch Block and Left Ventricular Activation Delay. J Am Heart Assoc 2018; 7:e007489. [PMID: 29432133 PMCID: PMC5850248 DOI: 10.1161/jaha.117.007489] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Accepted: 11/30/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND QRS narrowing following cardiac resynchronization therapy with biventricular (BiV) or left ventricular (LV) pacing is likely affected by patient-specific conduction characteristics (PR, qLV, LV-paced propagation interval), making a universal programming strategy likely ineffective. We tested these factors using a novel, device-based algorithm (SyncAV) that automatically adjusts paced atrioventricular delay (default or programmable offset) according to intrinsic atrioventricular conduction. METHODS AND RESULTS Seventy-five patients undergoing cardiac resynchronization therapy (age 66±11 years; 65% male; 32% with ischemic cardiomyopathy; LV ejection fraction 28±8%; QRS duration 162±16 ms) with intact atrioventricular conduction (PR interval 194±34, range 128-300 ms), left bundle branch block, and optimized LV lead position were studied at implant. QRS duration (QRSd) reduction was compared for the following pacing configurations: nominal simultaneous BiV (Mode I: paced/sensed atrioventricular delay=140/110 ms), BiV+SyncAV with 50 ms offset (Mode II), BiV+SyncAV with offset that minimized QRSd (Mode III), or LV-only pacing+SyncAV with 50 ms offset (Mode IV). The intrinsic QRSd (162±16 ms) was reduced to 142±17 ms (-11.8%) by Mode I, 136±14 ms (-15.6%) by Mode IV, and 132±13 ms (-17.8%) by Mode II. Mode III yielded the shortest overall QRSd (123±12 ms, -23.9% [P<0.001 versus all modes]) and was the only configuration without QRSd prolongation in any patient. QRS narrowing occurred regardless of QRSd, PR, or LV-paced intervals, or underlying ischemic disease. CONCLUSIONS Post-implant electrical optimization in already well-selected patients with left bundle branch block and optimized LV lead position is facilitated by patient-tailored BiV pacing adjusted to intrinsic atrioventricular timing using an automatic device-based algorithm.
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Affiliation(s)
| | | | | | | | - Carlo Pappone
- Department of Electrophysiology, IRCCS Policlinico San Donato, San Donato Milanese, Italy
| | | | | | | | - Bernard Thibault
- Electrophysiology Service, Montreal Heart Institute, Montreal, Canada
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Improvement of Reverse Remodeling Using Electrocardiogram Fusion-Optimized Intervals in Cardiac Resynchronization Therapy. JACC Clin Electrophysiol 2018; 4:181-189. [DOI: 10.1016/j.jacep.2017.11.020] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Revised: 11/13/2017] [Accepted: 11/16/2017] [Indexed: 01/20/2023]
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Rowe MK, Kaye GC. Advances in atrioventricular and interventricular optimization of cardiac resynchronization therapy - what's the gold standard? Expert Rev Cardiovasc Ther 2018; 16:183-196. [PMID: 29338475 DOI: 10.1080/14779072.2018.1427582] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
INTRODUCTION Cardiac resynchronization therapy (CRT) is one of the most important advances in heart failure management in the last twenty years. Approximately one-third of patients appear not to respond to therapy. Although there are a number of possible mechanisms for non-response, an important factor is suboptimal atrioventricular (AV) and interventricular (VV) timing intervals. There remains controversy over whether routinely optimizing intervals is necessary and there is no agreed gold standard methodology. Optimization has classically been performed using echocardiography which has limits related to resource use, time-cost and variable reproducibility. Newer optimization methods using device-based sensors and algorithms show promise in reducing heart-failure hospitalization compared with echocardiography. Areas covered: This review outlines the rationale for optimization, the principles of AV and VV optimization, the standard echocardiographic approach and newer device-based algorithms and the evidence base for their use. Expert commentary: The incremental gains of optimization are likely to be real, but small, compared to the overall improvement gained from cardiac resynchronization itself. At this time routine optimization may not be mandatory but should be performed where there is no response to CRT. Device-based optimization algorithms appear to be practical and in some cases, deliver superior clinical outcomes compared to echocardiography.
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Affiliation(s)
- Matthew K Rowe
- a Department of Cardiology , Princess Alexandra Hospital , Brisbane , Australia.,b Faculty of Medicine , The University of Queensland , Brisbane , Australia
| | - Gerald C Kaye
- a Department of Cardiology , Princess Alexandra Hospital , Brisbane , Australia.,b Faculty of Medicine , The University of Queensland , Brisbane , Australia
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Ventricular dyssynchrony assessment using ultra-high frequency ECG technique. J Interv Card Electrophysiol 2017; 49:245-254. [PMID: 28695377 PMCID: PMC5543201 DOI: 10.1007/s10840-017-0268-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2016] [Accepted: 06/20/2017] [Indexed: 11/17/2022]
Abstract
Purpose The aim of this proof-of-concept study is to introduce new high-dynamic ECG technique with potential to detect temporal-spatial distribution of ventricular electrical depolarization and to assess the level of ventricular dyssynchrony. Methods 5-kHz 12-lead ECG data was collected. The amplitude envelopes of the QRS were computed in an ultra-high frequency band of 500–1000 Hz and were averaged (UHFQRS). UHFQRS V lead maps were compiled, and numerical descriptor identifying ventricular dyssynchrony (UHFDYS) was detected. Results An electrical UHFQRS maps describe the ventricular dyssynchrony distribution in resolution of milliseconds and correlate with strain rate results obtained by speckle tracking echocardiography. The effect of biventricular stimulation is demonstrated by the UHFQRS morphology and by the UHFDYS descriptor in selected examples. Conclusions UHFQRS offers a new and simple technique for assessing electrical activation patterns in ventricular dyssynchrony with a temporal-spatial resolution that cannot be obtained by processing standard surface ECG. The main clinical potential of UHFQRS lies in the identification of differences in electrical activation among CRT candidates and detection of improvements in electrical synchrony in patients with biventricular pacing. Electronic supplementary material The online version of this article (doi:10.1007/s10840-017-0268-0) contains supplementary material, which is available to authorized users.
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ter Horst IA, Bogaard MD, Tuinenburg AE, Mast TP, de Boer TP, Doevendans PA, Meine M. The concept of triple wavefront fusion during biventricular pacing: Using the EGM to produce the best acute hemodynamic improvement in CRT. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2017; 40:873-882. [DOI: 10.1111/pace.13118] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Revised: 04/02/2017] [Accepted: 05/02/2017] [Indexed: 02/02/2023]
Affiliation(s)
- Iris A.H. ter Horst
- Department of Cardiology; University Medical Center Utrecht; Utrecht The Netherlands
| | - Margot D. Bogaard
- Department of Cardiology; University Medical Center Utrecht; Utrecht The Netherlands
| | - Anton E. Tuinenburg
- Department of Cardiology; University Medical Center Utrecht; Utrecht The Netherlands
| | - Thomas P. Mast
- Department of Cardiology; University Medical Center Utrecht; Utrecht The Netherlands
| | - Teun P. de Boer
- Department of Medical Physiology; University Medical Center Utrecht; Utrecht The Netherlands
| | | | - Mathias Meine
- Department of Cardiology; University Medical Center Utrecht; Utrecht The Netherlands
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Burri H, Prinzen FW, Gasparini M, Leclercq C. Left univentricular pacing for cardiac resynchronization therapy. Europace 2017; 19:912-919. [PMID: 28339579 DOI: 10.1093/europace/euw179] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
This review describes the rationale and published evidence for left univentricular pacing for cardiac resynchronization therapy, gives an overview of the existing optimization algorithms featuring this mode, and discusses future perspectives.
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Affiliation(s)
- Haran Burri
- Cardiology Department, University Hospital of Geneva, Geneva, Switzerland
| | - Frits W Prinzen
- Department of Physiology, Maastricht University, Maastricht, The Netherlands
| | - Maurizio Gasparini
- EP and Pacing Unit, Humanitas Research Hospital IRCCS, Rozzano, Milano, Italy
| | - Christophe Leclercq
- Department of Cardiology, Service de Cardiologie et Maladies Vasculaires Rennes University Hospital, Rennes, France
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Abstract
Nonresponse to cardiac resynchronization therapy (CRT) is still a major issue in therapy expansion. The description of fast, simple, cost-effective methods to optimize CRT could help in adapting pacing intervals to individual patients. A better understanding of the importance of appropriate patient selection, left ventricular lead placement, and device programming, together with a multidisciplinary approach and an optimal follow-up of the patients, may reduce the percentage of nonresponders.
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Affiliation(s)
- José María Tolosana
- Hospital Clinic, Universitat de Barcelona, Villarroel 170, Barcelona, Catalonia 08036, Spain
| | - Lluís Mont
- Hospital Clinic, Universitat de Barcelona, Villarroel 170, Barcelona, Catalonia 08036, Spain.
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Cobb DB, Gold MR. The Role of Atrioventricular and Interventricular Optimization for Cardiac Resynchronization Therapy. Heart Fail Clin 2017; 13:209-223. [DOI: 10.1016/j.hfc.2016.07.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
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Cobb DB, Gold MR. The Role of Atrioventricular and Interventricular Optimization for Cardiac Resynchronization Therapy. Card Electrophysiol Clin 2015; 7:765-779. [PMID: 26596818 DOI: 10.1016/j.ccep.2015.08.008] [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] [Indexed: 06/05/2023]
Abstract
Many patients with left ventricular systolic dysfunction may benefit from cardiac resynchronization therapy; however, approximately 30% of patients do not experience significant clinical improvement with this treatment. AV and VV delay optimization techniques have included echocardiography, device-based algorithms, and several other novel noninvasive techniques. Using these techniques to optimize device settings has been shown to improve hemodynamic function acutely; however, the long-term clinical benefit is limited. In most cases, an empiric AV delay with simultaneous biventricular or left ventricular pacing is adequate. The value of optimization of these intervals in "nonresponders" still requires further investigation.
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Affiliation(s)
- Daniel B Cobb
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Michael R Gold
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, SC, USA.
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Abstract
Nonresponse to cardiac resynchronization therapy (CRT) is still a major issue in therapy expansion. The description of fast, simple, cost-effective methods to optimize CRT could help in adapting pacing intervals to individual patients. A better understanding of the importance of appropriate patient selection, left ventricular lead placement, and device programming, together with a multidisciplinary approach and an optimal follow-up of the patients, may reduce the percentage of nonresponders.
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Liang Y, Yu H, Zhou W, Xu G, Sun YI, Liu R, Wang Z, Han Y. Left Ventricular Lead Placement Targeted at the Latest Activated Site Guided by Electrophysiological Mapping in Coronary Sinus Branches Improves Response to Cardiac Resynchronization Therapy. J Cardiovasc Electrophysiol 2015; 26:1333-9. [PMID: 26249040 DOI: 10.1111/jce.12771] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2015] [Revised: 06/29/2015] [Accepted: 07/26/2015] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Electrophysiological mapping (EPM) in coronary sinus (CS) branches is feasible for guiding LV lead placement to the optimal, latest activated site at cardiac resynchronization therapy (CRT) procedures. However, whether this procedure optimizes the response to CRT has not been demonstrated. This study was to evaluate effects of targeting LV lead at the latest activated site guided by EPM during CRT. METHODS Seventy-six consecutive patients with advanced heart failure who were referred for CRT were divided into mapping (MG) and control groups (CG). In MG, the LV lead, also used as a mapping bipolar electrode, was placed at the latest activated site determined by EPM in CS branches. In CG, conventional CRT procedure was performed. Patients were followed for 6 months after CRT. RESULTS Baseline characteristics were comparable between the 2 groups. In MG (n = 29), EPM was successfully performed in 85 of 91 CS branches during CRT. A LV lead was successfully placed at the latest activated site guided by EPM in 27 (93.1%) patients. Compared with CG (n = 47), MG had a significantly higher rate (86.2% vs. 63.8%, P = 0.039) of response (>15% reduction in LV end-systolic volume) to CRT, a higher percentage of patients with clinical improvement of ≥2 NYHA functional classes (72.4% vs. 44.7%, P = 0.032), and a shorter QRS duration (P = 0.004). CONCLUSIONS LV lead placed at the latest activated site guided by EPM resulted in a significantly greater CRT response, and a shorter QRS duration.
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Affiliation(s)
- Yanchun Liang
- Department of Cardiology, General Hospital of Shenyang Military Region, Shenyang, China
| | - Haibo Yu
- Department of Cardiology, General Hospital of Shenyang Military Region, Shenyang, China
| | - Weiwei Zhou
- Department of Cardiology, General Hospital of Shenyang Military Region, Shenyang, China
| | - Guoqing Xu
- Department of Cardiology, General Hospital of Shenyang Military Region, Shenyang, China
| | - Y I Sun
- Department of Cardiology, General Hospital of Shenyang Military Region, Shenyang, China
| | - Rong Liu
- Department of Cardiology, General Hospital of Shenyang Military Region, Shenyang, China
| | - Zulu Wang
- Department of Cardiology, General Hospital of Shenyang Military Region, Shenyang, China
| | - Yaling Han
- Department of Cardiology, General Hospital of Shenyang Military Region, Shenyang, China
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50
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van Deursen CJM, Wecke L, van Everdingen WM, Ståhlberg M, Janssen MHG, Braunschweig F, Bergfeldt L, Crijns HJGM, Vernooy K, Prinzen FW. Vectorcardiography for optimization of stimulation intervals in cardiac resynchronization therapy. J Cardiovasc Transl Res 2015; 8:128-37. [PMID: 25743446 PMCID: PMC4382533 DOI: 10.1007/s12265-015-9615-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2014] [Accepted: 02/12/2015] [Indexed: 11/26/2022]
Abstract
Current optimization of atrioventricular (AV) and interventricular (VV) intervals in cardiac resynchronization therapy (CRT) is time consuming and subject to noise. We aimed to prove the principle that the best hemodynamic effect of CRT is achieved by cancelation of opposing electrical forces, detectable from the QRS morphology in the 3D vectorcardiogram (VCG). Different degrees of left (LV) and right ventricular (RV) pre-excitation were induced, using variation in AV intervals during LV pacing in 20 patients with left bundle branch block (LBBB) and variation in VV intervals during biventricular pacing in 18 patients with complete AV block or atrial fibrillation. The smallest QRS vector area identified stimulation intervals with minimal systolic stretch (median difference [IQR] 20 ms [−20, 20 ms] and maximal hemodynamic response (10 ms [−20, 40 ms]). Reliability of VCG measurements was superior to hemodynamic measurements. This study proves the principle that VCG analysis may allow easy and reliable optimization of stimulation intervals in CRT patients.
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Affiliation(s)
- Caroline J M van Deursen
- Departments of Physiology, Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands
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